Deutsches Arzteblatt international最新文献

{"title":"Evaluation of an Automated Decision Aid for the Further Referral of Emergency Room Patients—A Prospective Cohort Study.","authors":"Anna Slagman, Anne Bremicker, Martin Möckel, Larissa Eienbröker, Antje Fischer-Rosinský, André Gries","doi":"10.3238/arztebl.m2024.0191","DOIUrl":"10.3238/arztebl.m2024.0191","url":null,"abstract":"<p><strong>Background: </strong>Instruments for the initial evaluation of emergency room patients as an aid to their onward referral to ambulatory care structures are a matter of current interest. In this study, we assess the safety of the software application SmED-Kontakt+ for this purpose. SmED is an abbreviation for Strukuturierte Medizinische Ersteinschätzung Deutschland, \"structured initial medical evaluation in Germany.\"</p><p><strong>Methods: </strong>In this prospective cohort study, we compared the recommendations of SmED-Kontakt+ concerning the time and place of further care with those of the treating physicians. The subjects were adult patients who were able to walk and had presented themselves to the emergency room. Whenever SmED-Kontakt+ assessed the situation less critically than the physicians, and in 5% of the remaining cases, the potential endangerment of patient safety was assessed by an expert panel (expected value <1%).</p><p><strong>Results: </strong>In a total of 1840 cases, SmED-Kontakt+ agreed with the physicians' assessment in 353 (19%). The assessment of SmED-Kontakt+ was more critical in 1221 cases (66%) and less critical in 266 (15%; potential undertriage). There was potential endangerment in 49 cases (2.7%; 95% confidence interval [2.0; 3.5]). Potential endangerment was less common among patients in the more urgent recommendation categories [0.1; 2.6] and more common in the categories of a recommended outpatient physician visit or telephone consultation within or beyond 24 hours [2.4; 17.2].</p><p><strong>Conclusion: </strong>SmED-Kontakt+ generally assessed these patients' needs for further care as more urgent than the treating physicians did. Nevertheless, the percentage of potentially endangered patients was higher than expected. We conclude that further care should be provided in timely fashion with an obligatory appointment. The sites of further ambulatory care should be immediately accessible and properly equipped. Patients should not be referred for further care at later times on the basis of an SmED-Kontakt+ assessment.</p>","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142343496","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"In Reply.","authors":"Daniel Schmitz","doi":"10.3238/arztebl.m2024.0173","DOIUrl":"10.3238/arztebl.m2024.0173","url":null,"abstract":"","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11551544/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142496926","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Allocation Rules and Age-Dependent Waiting Times for Kidney Transplantation.","authors":"Benedikt Kolbrink, Nassim Kakavand, Jakob C Voran, Helena U Zacharias, Axel Rahmel, Serge Vogelaar, Silke Schicktanz, Felix Braun, Roland Schmitt, Friedrich A von Samson-Himmelstjerna, Kevin Schulte","doi":"10.3238/arztebl.m2024.0137","DOIUrl":"10.3238/arztebl.m2024.0137","url":null,"abstract":"<p><strong>Background: </strong>Rigid age limits in the current allocation system for post-mortem donor kidneys in Germany may have problematic effects. The new German national transplantion registry enables data analysis with respect to this question.</p><p><strong>Methods: </strong>Using anonymized data from the German national transplantion registry, we extracted and evaluated information on the recipients and postmortem donors of kidneys that were allocated in Germany through Eurotransplant over the period 2006-2020.</p><p><strong>Results: </strong>Data on 19 664 kidney transplantations in Germany from 2006 to 2020 were analyzed. The median waiting time for kidney transplantation was 5.8 years. Persons under age 18 waited a median of 1.7 years; persons aged 18 to 64, 7.0 years; and persons aged 65 and older, 3.8 years. Over the period of observation, postmortem kidneys were transplanted into 401 people of age 64 (2.0% of all organ recipients) and 1,393 people of age 65 (7.1% of all organ recipients). The difference in waiting times between allocation programs for persons under age 65 (ETKAS, \"Eurotransplant Kidney Allocation System\") and those aged 65 and older (ESP, \"Eurotransplant Senior Program\") increased over the period of observation, from 2.6 years in 2006-2010 to 4.1 years in 2017-2020.</p><p><strong>Conclusion: </strong>The rigid age limits in the current allocation rules for post-mortem kidney donations in Germany are prolonging the waiting times for transplants among patients aged 18 to 64. We think these rules need to be fundamentally reassessed.</p>","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11551543/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141901277","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Treatment of Metastatic Renal Cell Carcinoma.","authors":"Philipp Ivanyi, Tabea Fröhlich, Viktor Grünwald, Stefanie Zschäbitz, Jens Bedke, Christian Doehn","doi":"10.3238/arztebl.m2024.0147","DOIUrl":"10.3238/arztebl.m2024.0147","url":null,"abstract":"<p><strong>Background: </strong>Approximately 15 000 people receive a diagnosis of renal cell carcinoma (RCC) in Germany each year; in 20-30% of cases, metastatic RCC (mRCC) is already present at the time of diagnosis. This disease in the metastatic stage is still mainly treated palliatively, yet the multimodal therapeutic landscape has changed markedly over the past 15 years, with the approval of many new treatments for patients with mRCC.</p><p><strong>Methods: </strong>This review is based on prospective studies retrieved by a selective search in PubMed and the ASCO and ESMO databases and on the German and European oncological and urological guidelines for RCC.</p><p><strong>Results: </strong>Drugs are the mainstay of treatment. mRCC can be treated with a combination of two immune checkpoint inhibitors (CPIs), a CPI and a tyrosine-kinase inhibitor (TKI) (evidence level IA), or a TKI as monotherapy (evidence level IIC-IC). With prognosis-based sequential drug treatment, a mean progressionfree survival of 12 to 24 months and an overall survival of approximately 50 months can be achieved from the time of initiation of first-line therapy. Aside from pharmacotherapy, the multidisciplinary tumor board should evaluate the indications for local treatments such as cytoreductive nephrectomy, metastasectomy, and radiotherapy, depending on the individual prognostic constellation and the patient's present condition.</p><p><strong>Conclusion: </strong>Optimal individualized decisions require a high level of expertise and the collabo - ration of a multidisciplinary tumor board. Older prognostic parameters currently play a leading role in decision-making, while predictive parameters and molecular markers are not yet adequately validated.</p>","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11551541/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141999574","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Quality Assurance in Aneurysmal Subarachnoid Hemorrhage.","authors":"Joachim Berkefeld, Björn Misselwitz, Marco Stein","doi":"10.3238/arztebl.m2024.0107","DOIUrl":"10.3238/arztebl.m2024.0107","url":null,"abstract":"","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11551547/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142496927","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Unanswered Questions Remain.","authors":"Peter P Schmittenbecher","doi":"10.3238/arztebl.m2024.0143","DOIUrl":"10.3238/arztebl.m2024.0143","url":null,"abstract":"","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11551540/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142496928","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Diagnosis and Treatment of Tricuspid Regurgitation.","authors":"Thomas J Stocker, Christian Besler, Hendrik Treede, Jörg Hausleiter","doi":"10.3238/arztebl.m2024.0104","DOIUrl":"10.3238/arztebl.m2024.0104","url":null,"abstract":"<p><strong>Background: </strong>It is estimated that 6% of persons over age 75 have clinically relevant tricuspid regurgitation (TR). This condition carries a high mortality and is of particular interest because of the recent development of new interventional treatments.</p><p><strong>Methods: </strong>This review is based on publications that were retrieved by a selective search in the PubMed database for randomized controlled trials (RCTs), observational studies, registry studies, expert recommendations, and current international guidelines.</p><p><strong>Results: </strong>The evidence reveals that TR is an independent cause of mortality. Mortality is correlated with the severity of TR: approximately 35% of patients with severe TR and right heart failure die within 1 year, and about 60% within 3 years. The clinical course varies depending on the etiology (primary TR, atrial/ventricular secondary TR, association with pacemaker systems). In the outpatient setting, timely diagnosis by transthoracic echocardiography is crucial. The options for pharmacotherapy are essentially limited to diuretic treatment (grade 2a recommendation). Early referral to a specialized heart valve center is essential for the prevention of irreversible damage of the right heart and secondary end-organ damage, including cardiohepatic and cardiorenal syndromes. In the heart valve center, an extended diagnostic evaluation with multimodal imaging is followed by a case discussion by the interdisciplinary cardiac team, with individual evaluation of the treatment options. The first randomized controlled trial of treatment for TR yielded a win ratio of 1.48 (95% confidence interval, [1.06; 2.13]) for interventional treatment (edge-to-edge repair) compared to optimal medical therapy.</p><p><strong>Conclusion: </strong>As the understanding of tricuspid regurgitation improves, strategies for its interventional treatment are undergoing steady development, with the aim of lowering the mortality of this condition.</p>","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11551545/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141418279","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Evaluation of a Digital Decision Aid for Knee Replacement Surgery.","authors":"Jörg Lützner, Stefanie Deckert, Franziska Beyer, Waldemar Hahn, Jürgen Malzahn, Martin Sedlmayr, Klaus-Peter Günther, Jochen Schmitt, Toni Lange","doi":"10.3238/arztebl.m2024.0152","DOIUrl":"10.3238/arztebl.m2024.0152","url":null,"abstract":"<p><strong>Background: </strong>We studied whether an individualized digital decision aid can improve decision-making quality for or against knee arthroplasty.</p><p><strong>Methods: </strong>An app-based decision aid (EKIT tool) was developed and studied in a stepped-wedge, cluster-randomized trial. Consecutive patients with knee osteoarthritis who were candidates for knee replacement were included in 10 centers in Germany. All subjects were asked via app on a tablet about their symptoms, prior treatments, and preferences and goals for treatment. For the subjects in the intervention group, the EKIT tool was used in the doctor-patient discussion to visualize the individual disease burden and degree of fulfillment of the indication criteria, and structured information on knee arthroplasty was provided. In the control group, the discussion was conducted without the EKIT tool in accordance with the local standard in each participating center. The primary endpoint was the quality of the patient's decision on the basis of the discussion of indications, as measured with the Hip and Knee Quality Decision Instrument (HK-DQI). (Registration number: ClinicalTrials.gov:NCT04837053).</p><p><strong>Results: </strong>1092 patients were included, and data from 1055 patients were analyzed (616 in the intervention group and 439 in the control group). Good decision quality, as rated by the HKDQI, was achieved by 86.0% of patients in the intervention group and 67.4% of patients in the control group (relative risk, 1.24; 95 % confidence interval, [1.15; 1.33]).</p><p><strong>Conclusion: </strong>A digital decision aid significantly improved the quality of decision-making for or against knee replacement surgery. The widespread use of this instrument may have an even larger effect, as this trial was conducted mainly in hospitals with high case numbers.</p>","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11551546/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141897058","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"VEXAS Syndrome in a Male Patient With Fever and Rash.","authors":"Katharina A Kälber, Jochen Hoffmann, Norbert Blank","doi":"10.3238/arztebl.m2024.0043","DOIUrl":"10.3238/arztebl.m2024.0043","url":null,"abstract":"","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11551542/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142496929","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Reality of Healthcare Provision.","authors":"Patrik Finkenwirth","doi":"10.3238/arztebl.m2024.0028","DOIUrl":"10.3238/arztebl.m2024.0028","url":null,"abstract":"","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-08-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11542572/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142460407","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}