Deutsches Arzteblatt international最新文献

{"title":"Digital Medication Management in Polypharmacy.","authors":"Robin Brünn, Jale Basten, Dorothea Lemke, Alexandra Piotrowski, Sara Söling, Bastian Surmann, Wolfgang Greiner, Daniel Grandt, Petra Kellermann-Mühlhoff, Sebastian Harder, Paul Glasziou, Rafael Perera, Juliane Köberlein-Neu, Peter Ihle, Marjan van den Akker, Nina Timmesfeld, Christiane Muth","doi":"10.3238/arztebl.m2024.0007","DOIUrl":"10.3238/arztebl.m2024.0007","url":null,"abstract":"<p><strong>Background: </strong>Inappropriate drug prescriptions for patients with polypharmacy can have avoidable adverse consequences. We studied the effects of a clinical decision-support system (CDSS) for medication management on hospitalizations and mortality.</p><p><strong>Methods: </strong>This stepped-wedge, cluster-randomized, controlled trial involved an open cohort of adult patients with polypharmacy in primary care practices (=clusters) in Westphalia-Lippe, Germany. During the period of the intervention, their medication lists were checked annually using the CDSS. The CDSS warns against inappropriate prescriptions on the basis of patient-related health insurance data. The combined primary endpoint consisted of overall mortality and hospitalization for any reason. The secondary endpoints were mortality, hospitalizations, and high-risk prescription. We analyzed the quarterly health insurance data of the intention- to-treat population with a mixed logistic model taking account of clustering and repeated measurements. Sensitivity analyses addressed effects of the COVID-19 pandemic and other effects.</p><p><strong>Results: </strong>688 primary care practices were randomized, and data were obtained on 42 700 patients over 391 994 quarter years. No significant reduction was found in either the primary endpoint (odds ratio [OR] 1.00; 95% confidence interval [0.95; 1.04]; p = 0.8716) or the secondary endpoints (hospitalizations: OR 1.00 [0.95; 1.05]; mortality: OR 1.04 [0.92; 1.17]; high-risk prescription: OR 0.98 [0.92; 1.04]).</p><p><strong>Conclusion: </strong>The planned analyses did not reveal any significant effect of the intervention. Pandemicadjusted analyses yielded evidence that the mortality of adult patients with polypharmacy might potentially be lowered by the CDSS. Controlled trials with appropriate follow-up are needed to prove that a CDSS has significant effects on mortality in patients with polypharmacy.</p>","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-04-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11381212/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139912337","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 Clinical Features of Hereditary Alpha-Tryptasemia.","authors":"Dagmar von Bubnoff, Daniel Koch, Hannah Stocker, Ralf J Ludwig, Friederike Wortmann, Nikolas von Bubnoff","doi":"10.3238/arztebl.m2023.0287","DOIUrl":"10.3238/arztebl.m2023.0287","url":null,"abstract":"<p><strong>Background: </strong>Hereditary alpha-tryptasemia (HAT) is a genetic predisposition of autosomal dominant inheritance that leads to a high normal (≥ 8-11.4 μg/L) or pathologically elevated (>11.4 μg/L) basal serum tryptase (BST) concentration. Its prevalence in the United Kingdom and France is reportedly 5%-6%; its prevalence in Germany is unknown. Symptomatic persons with HAT suffer from a complex constellation of symptoms. As described in this review, HAT is an important differential diagnosis in interdisciplinary practice.</p><p><strong>Methods: </strong>This review is based on publications about HAT retrieved by a selective search in PubMed, on relevant presentations at scientific meetings, and on our clinical experience. We also collected our own data on the prevalence and clinical manifestations of HAT.</p><p><strong>Results: </strong>According to the literature, HAT is very common among patients in medical centers with BST values of 8 μg/L or above (64-74%). HAT is most commonly associated with neuropsychiatric symptoms such as exhaustion (85%), depressive episodes (59%), sleep disturbances (69%), and memory impairment (59%-68%), followed by gastrointestinal symptoms such as irritable bowel (30%-60%), nausea (51%), and reflux (49%-77%). Typical mast cell-mediated symptoms, such as flushing (47%), itch (69%), urticaria (37%), and anaphylaxis (14%-28%), are reported as well. Less commonly reported are cardio vascular manifestations, such as hypotonia, dizziness, and tachycardia (34%), and joint hyper - mobility (28%). HAT is more common among patients with systemic mastocytosis (SM; 12%-21%). It is often associated with severe anaphylaxis induced by insect toxins or unknown triggers. The therapeutic options include treatment with antihistamines, mastcell stabilizers, or IgE antibodies.</p><p><strong>Conclusion: </strong>A diagnosis of hereditary alphatryptasemia can be strongly suspected on the basis of thorough history-taking and BST measurement and then confirmed by molecular genetic testing.</p>","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-04-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11381211/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139520424","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":"Indications for the Postpartum Oral Glucose Tolerance Test.","authors":"Heinke Adamczewski, Dietmar Weber, Judith Klein, Manuela Behling, Matthias Kaltheuner","doi":"10.3238/arztebl.m2024.0034","DOIUrl":"10.3238/arztebl.m2024.0034","url":null,"abstract":"<p><strong>Background: </strong>Gestational diabetes mellitus (GDM) affects more than 50 000 pregnant women in Germany every year. In postpartum diabetes screening, a 75 g oral glucose tolerance test (OGT) is recommended. This is time-consuming and can have side effects, and only 40% of mothers take it. The determination of pre-test probabilities might obviate the need for OGT except in women who are at particular risk.</p><p><strong>Methods: </strong>We analyzed 5444 cases of GDM from the GestDiab registry over the period 2015-2019. The pretest probabilities of a postpartum diagnosis of diabetes mellitus (DM) or prediabetes were calculated on the basis of clinical variables including postpartum venous fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c).</p><p><strong>Results: </strong>In 0.77% of mothers with a history of GDM in whom DM was not detected by FPG or HbA1c, postpartum DM was diagnosed on the basis of the 2-hour value in the OGT. Individual estimation of the pre-test probability of a diagnosis by OGT of postpartum DM or prediabetes was possible with the aid of the FPG and HbA1c values and clinical predictors including insulin treatment during pregnancy, obesity, GDM diagnosed before 24 weeks of gestation, age over 35, and a 1-hour value in the diagnostic OGT during pregnancy of 180 mg/dL (10.0 mmol/L) or above. The pretest probability of postpartum DM in the study group ranged from 0.11% to 4.17%, and that of postpartum prediabetes from 6.4% to 16.3%.</p><p><strong>Conclusion: </strong>The probability of a diagnosis of postpartum diabetes by OGT after GDM can be estimated in postpartum screening on the basis of various parameters. This enables risk-adapted counseling of the affected women along with a long-term strategy for diabetes prevention and follow-up. The findings of our study should be verified by further research.</p>","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-04-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11381206/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140049055","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":"Indoor Mold.","authors":"Julia Hurraß, Dennis Nowak, Birger Heinzow, Marcus Joest, Jannik Stemler, Gerhard A Wiesmüller","doi":"10.3238/arztebl.m2024.0018","DOIUrl":"10.3238/arztebl.m2024.0018","url":null,"abstract":"<p><strong>Background: </strong>According to self-reported frequencies, every fifth or sixth dwelling in Germany is affected by dampness and/or mold. This carries a potential risk to health.</p><p><strong>Methods: </strong>This review is based on pertinent publications retrieved by a selective literature search and inquiry in the GENESIS database, on the AWMF guideline on the medical clinical diagnosis of indoor mold exposure, as updated in 2023, and on the relevant contents of other current guidelines. Based on this research, we present an algorithm for the evaluation of health problems that may be due to mold in indoor environments.</p><p><strong>Results: </strong>A rational diagnostic work-up begins with history-taking and physical examination, with attention to risk factors-above all, immune compromise and atopy. If there is evidence of atopy, targeted allergy diagnostics should be performed, consisting of a skin prick test and/or measurement of specific IgE antibodies, supplemented whenever indicated by provocative testing and cellular test systems. If the patient's immune response is compromised, the immediate cessation of mold exposure has absolute priority. Any suspected invasive fungal infection should be evaluated with radiological, microbiological, serological, and immunological testing. Indoor measurements of mold fungi, microbial volatile organic compounds (MVOC), and/or mycotoxins are generally not indicated as part of the medical evaluation; nor are blood or urine tests for particular mold components or metabolites.</p><p><strong>Conclusion: </strong>Mold in indoor environments should be dealt with by rapid exposure elimination for patients at risk, the rational diagnostic evaluation of any symptoms and signs of disease, and patient education about the possibilities and limitations of diagnostic testing and the generally limited utility of measurements in the affected interior spaces.</p>","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-04-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11381209/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139930508","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":"In Reply.","authors":"Ulf Teichgräber, Maja Ingwersen","doi":"10.3238/arztebl.m2024.0010","DOIUrl":"10.3238/arztebl.m2024.0010","url":null,"abstract":"","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-04-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11381213/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141317073","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":"Further Options for Establishing Walking Training Groups.","authors":"Dmitriy Dovzhanskiy, Siamak Pourhassan","doi":"10.3238/arztebl.m2024.0009","DOIUrl":"10.3238/arztebl.m2024.0009","url":null,"abstract":"","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-04-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11381208/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141317072","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":"Differences in Anthropometric Measures Based on Sex, Age, and Health Status.","authors":"Michael J Stein, Beate Fischer, Patricia Bohmann, Wolfgang Ahrens, Klaus Berger, Hermann Brenner, Kathrin Günther, Volker Harth, Jana-Kristin Heise, André Karch, Carolina J Klett-Tammen, Lena Koch-Gallenkamp, Lilian Krist, Wolfgang Lieb, Claudia Meinke-Franze, Karin B Michels, Rafael Mikolajczyk, Katharina Nimptsch, Nadia Obi, Annette Peters, Tobias Pischon, Sabine Schipf, Börge Schmidt, Andreas Stang, Sigrid Thierry, Stefan N Willich, Kerstin Wirkner, Michael F Leitzmann, Anja M Sedlmeier","doi":"10.3238/arztebl.m2024.0016","DOIUrl":"10.3238/arztebl.m2024.0016","url":null,"abstract":"<p><strong>Background: </strong>Obesity is a worldwide health problem. We conducted detailed analyses of anthropometric measures in a comprehensive, population-based, current cohort in Germany.</p><p><strong>Methods: </strong>In the German National Cohort (NAKO), we analyzed cross-sectional data on body mass index (BMI), waist and hip circumference, subcutaneous (SAT) and visceral adipose tissue (VAT) as measured by ultrasound, and body fat percentage. The data were stratified by sex, age, and self-reported physicians' diagnoses of cardiovascular diseases (CVD), metabolic diseases (MetD), cardiometabolic diseases (CMD), and cancer.</p><p><strong>Results: </strong>Data were available from 204 751 participants (age, 49.9 ± 12.8 years; 50.5% women). Body size measures generally increased with age. Men had a higher BMI, larger waist circumference, and more VAT than women, while women had a larger hip circumference, more SAT, and a higher body fat percentage than men. For example, the mean BMI of participants over age 60 was 28.3 kg/m2 in men and 27.6 kg/m2 in women. CVD, MetD, and CMD were associated with higher anthropometric values, while cancer was not. For example, the mean BMI was 25.3 kg/m2 in healthy women, 29.4 kg/m2 in women with CMD, and 25.4 kg/m2 in women with cancer.</p><p><strong>Conclusion: </strong>Obesity is widespread in Germany, with notable differences between the sexes in anthro - pometric values. Obesity was more common in older participants and those with chronic diseases other than cancer. Elevated values were especially common in multimorbid individuals.</p>","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-04-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11539873/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139912336","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":"Planned Versus Emergency Admissions: Home Care Needs, Length of Stay, and Hospital Revenue.","authors":"Andreas Umgelter, Tobias Weismüller, Süha Dasdelen, Slatomir Wenske, Natalie Luther, Steffen Behrens","doi":"10.3238/arztebl.m2024.0004","DOIUrl":"10.3238/arztebl.m2024.0004","url":null,"abstract":"","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-04-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11539868/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141310330","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":"Midazolam for Post-Arrest Sedation in Pre-Hospital Emergency Care.","authors":"Gerrit Jansen, Eugen Latka, Michael Bernhard, Martin Deicke, Daniel Fischer, Annika Hoyer, Yacin Keller, André Kobiella, Sissy Linder, Bernd Strickmann, Lisa Marie Strototte, Karl Christian Thies, Kai Johanning, Vera von Dossow, Jochen Hinkelbein","doi":"10.3238/arztebl.m2023.0277","DOIUrl":"10.3238/arztebl.m2023.0277","url":null,"abstract":"<p><strong>Background: </strong>An out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) may need to be treated with airway management, emergency ventilation, invasive interventions, and post-arrest sedation. We investigated the influence of the use of midazolam for post-arrest sedation on achieving postresuscitation care targets and the associated risk of hemodynamic complications.</p><p><strong>Methods: </strong>All emergency rescue missions of the Dresden, Gütersloh, and Lippe medical rescue services in the years 2019-2021 were reviewed to identify adult patients who had OHCA, unconsciousness, and sustained ROSC with spontaneous circulation until arrival at the hospital; the findings were supplemented with data from the German Resuscitation Registry. Patients who received midazolam (alone or in combination with other anesthetic agents) for post-arrest sedation were compared with those who did not. The endpoints were the regaining of a systolic blood pressure ≥ 100 mmHg, end-tidal pCO2 35-45 mmHg, and oxygen saturation (SpO2) 94-98%. A propensity score analysis was used to adjust for age, sex, and variables potentially affecting hemodynamic status or the targets for oxygenation and ventilation.</p><p><strong>Results: </strong>There were 2335 cases of OHCA among 391 305 emer - gency rescue missions. 571 patients had ROSC before arrival in the hospital (24.5%; female, 33.6%; age, 68 ± 14 years). Of the 395 among them (69.2%) who were treated with postarrest sedation, 249 (63.0%) received midazolam. Patients who received midazolam reached the guideline- recommended targets for oxygenation, ventilation, and blood pressure more frequently than those who were not sedated: the respective odds ratios and 95% confidence intervals were 2.00 [1.20; 3.34], 1.57 [0.99; 2.48], and 1.41 [0.89; 2.21].</p><p><strong>Conclusion: </strong>The pre-hospital administration of midazolam leads to more frequent pre-hospital attainment of the oxygenation and ventilation targets in post-resuscitation care, without any evidence of an elevated risk of hemodynamic complications.</p>","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-04-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11539870/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139520418","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":"Perioperative Antibiotic Prophylaxis.","authors":"Christian Eckmann, Seven Johannes Sam Aghdassi, Alexander Brinkmann, Mathias Pletz, Jessica Rademacher","doi":"10.3238/arztebl.m2024.0037","DOIUrl":"10.3238/arztebl.m2024.0037","url":null,"abstract":"<p><strong>Background: </strong>Postoperative surgical site infections (SSI) account for almost 25% of all nosocomial infections in Germany and are a source of increased morbidity and mortality.</p><p><strong>Methods: </strong>This review is based on pertinent publications retrieved by a selective search in PubMed and on national and international guidelines.</p><p><strong>Results: </strong>The individual risk factors for SSI must be assessed before any surgical procedure. A body-mass index above 30 kg/m2 is associated with an unadjusted risk ratio of 1.35 [1.28; 1.41] for SSI, which rises to 3.29 [2.99; 3.62] if the patient is also immunosuppressed. The risk of SSI is also significantly higher with certain types of procedure. Perioperative antibiotic prophylaxis (PAP) is clearly indicated for operations that carry a high risk of SSI (e.g., colorectal surgery) and for those that involve the implantation of alloplastic material (e.g., hip endoprostheses). PAP can usually be administered with basic antibiotics such as cefazoline. The basic principles of PAP are that it should be given by the anesthesia team in the interval from 60 minutes preoperatively up to shortly before the incision, and that its administration should only be for a short period of time, usually as a single shot. Continuing PAP onward into the postoperative period leads to increased toxicity, bacterial superinfections, and antibiotic resistance.</p><p><strong>Conclusion: </strong>The evidence shows that perioperative antibiotic prophylaxis is a component of a bundle of measures that can help prevent SSI. Strict indications and adherence to the basic principles of PAP are essential for therapeutic success.</p>","PeriodicalId":11258,"journal":{"name":"Deutsches Arzteblatt international","volume":null,"pages":null},"PeriodicalIF":6.5,"publicationDate":"2024-04-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11539872/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140027685","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}