Deutsche medizinische Wochenschrift (1946)最新文献

Pathophysiology of kidney diseases frequently implies sterile inflammation, e.g. during glomerulonephritis or after renal transplantation. Recently, the relevance of systemic low-grade inflammation for chronic kidney disease (CKD) progression and complications of CKD have come into focus. In this review article, the etiology, and consequences of low-grade inflammation in CKD patients are discussed. Further, the potential of anti-inflammatory approaches to slow down CKD progression is addressed. Recent advances have resulted in FDA approval of colchicine for patients with preserved renal function and atherosclerosis. Thus, lastly, anti-inflammatory therapy of atherosclerosis in patients with or without CKD is outlined.Taken together, anti-inflammatory therapy offers novel opportunities to improve CKD progression, inhibit transition from acute to chronic kidney disease and reduce the risk of fatal long-term complications such as cardiovascular disease.

Chronic Obstructive Pulmonary Disease (COPD) is closely linked to cardiovascular disease (CVD), with up to 70% of COPD patients experiencing cardiovascular comorbidities. The coexistence of COPD and CVD significantly increases hospitalization rates, symptom burden, and mortality, particularly during acute exacerbations of COPD (AECOPD), which impose an increased risk of cardiovascular events - both during and shortly after these episodes. Mechanistic links between COPD and CVD include systemic inflammation, oxidative stress, endothelial dysfunction, and hypoxemia, all of which contribute to the progression of both conditions.Current management guidelines stress the importance of early screening and risk factor control for cardiovascular comorbidities in COPD patients. Different COPD therapies can affect cardiovascular outcomes in distinct ways. Recent research suggests that inhaled corticosteroids (ICS), either alone or as part of triple therapy (long-acting muscarinic antagonist [LAMA], long-acting beta-agonist [LABA], and ICS), may help reduce mortality and morbidity, particularly for those at higher risk. Furthermore, beta-blockers and statins have shown potential benefits for COPD patients with CVD, although their exact role is not entirely clear. Newer antidiabetic agents, such as SGLT-2 inhibitors, have also demonstrated promise in reducing exacerbation rates.This review emphasizes the need for an integrated care approach, highlighting the importance of personalized, guideline-driven therapies to enhance quality of life and clinical outcomes for COPD patients with cardiovascular comorbidities.

The 5 most important pillars of conservative lymphoedema therapy are (1) compression, (2) manual lymphatic drainage (MLD), (3) exercise, (4) skin and wound care, and (5) self-management. Without compression therapy the risk of cellulitis is increased and causes an elevated health/economic burden. The use of nocturnal compression shows advantages and a high degree of treatment adherence. The previous recommendation that compression should not be used for cellulitis has been cancelled. On the contrary, compression therapy is explicitly desirable for inflammatory dermatoses. The fact that lymphedema extremities show a 3-fold higher association with malignant skin tumours compared to unaffected extremities deserves attention. Using ICG lymphography, 4 different functional regions of lymphatic leg bundles were differentiated. The severity of the lymphoedema correlated with the kind of affected bundles. Vascularized lymph node transfer, which is a reconstructive lymphatic surgery procedure, was found to show evidence in terms of volume reduction, improved functionality, and better quality of life. The higher the BMI, the higher the risk of developing lymphoedema. Meta-analyses confirm the benefits of an active lifestyle with exercise and sporting activities in conjunction with patient education. Apparative systems for decongestion (intermittent pneumatic compression) usually force patients to remain immobile during application. Portable apparative compression systems are a promising alternative but are not yet available in Germany. Primary lymphoedema is not a uniform entity. The St. George's classification system shows the association of primary lymphoedema with systemic or syndromic diseases and vascular malformations as well. As a work-in-progress algorithm, it is a valuable aid in classifying primary lymphoedema, confirming the diagnosis and finding therapeutic approaches.

Loss of appetite is part of the so-called "sickness behavior", which is a uniform reaction to many diseases, mainly triggered by inflammatory signals. Whereas this pattern may have been an evolutionary advantage long time ago, loss of appetite with consecutive malnutrition nowadays represents more a collateral damage of many acute and chronic diseases.Protein-energy-malnutrition should be diagnosed with the recently globally consented criteria of the "Global Leadership Initiative on Malnutrition" (GLIM). These criteria comprise 3 phenotypic and 3 etiologic criteria. If one criterium of each group is fulfilled, the diagnosis can be made.Besides the disease related loss of appetite, there are many potential causes of malnutrition. The entire spectrum may reach from malignancies to insufficient support in functionally impaired older subjects. Frequently, several factors may play a role. The very complex spectrum of potential and frequent causes of malnutrition has been summarized in the DoMAP model.Malnutrition may lead to severe consequences such as muscle atrophy and sarcopenia, leading to falls and fractures, impaired function of the immune system with an increase of infections and impaired wound healing, all of which are connected with increased morbidity and mortality.Many meta-analyses and guidelines have demonstrated the effectiveness of nutritional therapy in malnourished patients. There is good evidence for various approaches, that may be utilized alone or in combination, depending on the situation and disease of each individual patient. Particularly, the EFFORT-study, a large prospective randomized controlled trial, has demonstrated, that a structured, but individualized approach may be most effective.

Novel developments in the diagnosis and treatment of endometrial cancer will likely improve the prognosis of early, advanced and recurrent tumors. Molecular pathology currently classifies endometrial carcinoma into 4 molecular subtypes with prognostic significance. POLE mutated tumors, amounting to about 7% of all endometrial cancer cases, dubbed "ultra-mutated", have an excellent prognosis in early stages - even without adjuvant therapy. Mismatch repair deficient (MMRd) tumors are called "hypermutated" and have an intermediate prognosis in early stages. In advanced stages, they are highly sensitive to immune checkpoint inhibitors which are an integral part of their treatment. The tumors with "no specific molecular profile" have a prognosis that is similar to MMRd endometrial cancers. Finally, TP53 mutated cancers have a dismal prognosis, and aggressive adjuvant therapy is indicated. The 2023 FIGO classification recognizes for the first time the prognostically favorable synchronous endometrial and ovarian carcinomas, the importance of lymph node metastases depending on size and pattern, and the relevance of peritoneal involvement inside versus outside the pelvis. In metastatic disease, in mismatch repair proficient cases, the combination of carboplatin and paclitaxel chemotherapy with durvalumab has been recently approved as first line therapy in the European Union, followed by maintenance therapy with the PARP inhibitor olaparib, in combination with durvalumab. For MMRd tumors, several immune checkpoint inhibitors in combination with chemotherapy or as monotherapy have been approved in recent years. Tumors that are overexpressing Her2/neu have an additional treatment option with trastuzumab.

The 2023 ESC Cardiomyopathy Guidelines offer a comprehensive framework for diagnosing and managing cardiomyopathies. Building on a nuanced classification system, the guidelines introduce phenotypic descriptions that integrate genetic and non-genetic etiologies. Notably, the guidelines redefine cardiomyopathies, such as non-dilated left ventricular cardiomyopathy, emphasizing detailed myocardial tissue characterization and advanced imaging techniques like cardiac magnetic resonance to enhance diagnosis and treatment. Additionally, the role of genetic testing is highlighted, including family screening and personalized risk stratification for sudden cardiac death prevention. The guidelines stress a patient-centered, multidisciplinary approach, ensuring individualized care across all life stages, from pediatric to adult care. Key updates include new therapeutic options, such as myosin inhibitors for hypertrophic cardiomyopathy. The guidelines also underscore the importance of distinguishing transient syndromes, such as Takotsubo syndrome, from chronic cardiomyopathies, recommending careful assessment of arrhythmias and phenotypic traits to avoid misclassification. This refined approach aims to optimize clinical outcomes through accurate diagnosis, genetic evaluation, and a focus on lifelong management.

Coeliac disease is the most common chronic inflammatory disease of the small intestine, with a prevalence of around 1% almost worldwide. It is caused by the consumption of cereals containing gluten (wheat, spelt, rye, barley). The initial diagnosis is made in equal proportions in children and adults. Classic symptoms are abdominal pain, diarrhea, malabsorption with anemia or osteoporosis, weight loss, and in children failure to thrive. Non-specific symptoms such as poor performance, headaches and joint pain are also common. Often undetected and untreated, coeliac disease can lead to serious complications, and up to 30% of adult coeliac patients suffer from associated autoimmune diseases, including thyroid and rheumatoid diseases or type 1 diabetes. The pathogenesis of coeliac disease is well studied. Incompletely digested gluten peptides reach the immune system of the intestinal mucosa and activate glute-reactive T cells, which lead to inflammation and atrophy of the absorptive villi. The prerequisite for the development of coeliac disease is the carrier status for HLA-DQ2 or DQ8, as well as the enzyme and coeliac disease autoantigen transglutaminase-2 expressed in the intestine, which modifies the gluten peptides by deamidation and thus increases their binding to HLA-DQ2/DQ8 and subsequent T-cell activation. Despite the gluten-free diet, 30-50% of diagnosed patients continue to suffer from symptoms with signs of inflammation, partly due to unavoidable minimal gluten contamination in everyday life. Supportive pharmacological therapy is therefore urgently needed. Promising therapeutic approaches are currently in clinical phase 2 development, including an inhibitor of intestinal TG2, blocking antibodies against interleukin-15 or Ox40 ligand, the improvement of the intestinal barrier using a sirtuin-6 agonist, as well as nanoparticular therapies that can induce tolerance to gluten by addressing the spleen or liver.

Extracorporeal cardiopulmonary resuscitation (ECPR) is an invasive medical intervention using mechanical circulatory support for treating cardiac arrest beyond the limits of conventional cardiopulmonary resuscitation (CCPR). ECPR uses veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to maintain organ perfusion while treating reversible causes of cardiac arrest. Commonly applied criteria to select suitable patients include witnessed cardiac arrest, early bystander CPR, and a time frame of less than 60 minutes from collapse to ECPR initiation.A meta-analysis by Low et al. (2023), which included 11 studies with 4,595 ECPR and 4,597 CCPR patients, demonstrated that ECPR was not only associated with higher survival rates, but also better long-term neurological outcomes. Additionally, a higher number of ECPR procedures per center was linked to reduced mortality rates. A 2024 updated meta-analysis confirmed these findings and demonstrated further that ECPR significantly reduced in-hospital mortality in patients with out-of-hospital cardiac arrest (OHCA).Further insights on this topic can be gained from the individual studies on ECPR for treatment of OHCA: In general, there are several different modalities of how ECPR can be deployed, ranging from implantation at the site of the index event vs. implantation in the hospital, and even the place of implantation in the hospital varies. However, it seems that the actual pathway of how the VA-ECMO is implanted is of lower importance, and highly depends on the local infrastructure of a given hospital (rural area vs. municipal area), while achieving the lowest possible low-flow time should be the primary goal.The available data also shows that, despite all the advances, ECPR is still a high-risk intervention which is very demanding on the personnel and requires an abundance of resources.Overall, ECPR is a promising therapy for patients with OHCA to improve survival with good neurological outcome, but only if applied in a highly structured and standardized way, and in carefully selected patients.

In spite of available vaccines the frequency of sepsis caused by Streptococcus pneumoniae still remains rather high.In the years 2015-2022 Streptococcus pneumoniae could be isolated from 925 blood cultures in our laboratory. Serotyping was performed from 754 strains. In addition, their in vitro susceptibility to some antibiotics was assessed.In this period 925 blood cultures were positive, predominantly from aged patients (older than 60 years) and more frequently from men than from women. In the years 2020 and 2021 less positive blood cultures were found, which could be interpreted as a result from non-pharmaceutical interventions preventing aerogenically transmitted diseases such as coronavirus infections during the epidemic. Children were also relatively susceptible in their first year of life. 653 strains were serotyped, with serotypes 3 and 8 predominating. 67% of the serotypes found were covered by the 20-valent conjugate vaccine whereas the polysaccharide vaccine (PPV23) included 75%. The vast majority of isolates was susceptible to penicillin, erythromycin as well as to doxycycline. Multi-drug resistant strains were not detected.A large part of the infections might have been prevented by vaccination assuming a high vaccine effectiveness. However, 27% of S. pneumoniae serotypes detected were not covered by any of the vaccines currently available.