Search

Background: Molecular profiling is currently not yet widespread in Germany and its potential for personalized treatment of solitary thyroid nodules is not exhausted. Method: Narrative assessment of the available options and their evidence based on the current international literature as well as discussion of the options in the German context from the perspective of a thyroid surgeon and a thyroid pathologist. Results: The commercial tests available, especially in the USA, for molecular profiling of thyroid nodules offer good rule-in and somewhat poorer rule-out options, as many differentiated thyroid carcinomas do not display genetic alterations. The costs of these tests and molecular pathology for nodule assessment are still high and the individual mutations have not yet been clearly characterized. Conclusion: It can be assumed that molecular profiling will become more important in the coming years and find its way into the clinical routine. At this point in time, however, there is not yet sufficient evidence of the clinical significance of most mutations in thyroid carcinomas to derive therapeutic consequences from them. [ABSTRACT FROM AUTHOR]

Robotic operations as a further development of conventional laparoscopic surgery have been introduced for nearly all interventions in visceral surgery during the last decade. They also currently have a high importance and acceptance in pancreatic surgery despite a relevant learning curve and high associated costs. Standard procedures, such as robotic distal pancreatectomy (RDP) and partial pancreatoduodenectomy (RPD) are most frequently performed, whereas extended resections, e.g., vascular reconstructions of the portal vein, are still limited to a small number of centers worldwide. Potential advantages of robotic pancreatic surgery compared to open surgery include, in particular, less blood loss and a faster postoperative recovery of the patients leading to a shorter hospital stay. Compared to conventional laparoscopic surgery, robotic approaches offer advantages with respect to better visualization and three-dimensional dexterity of the instruments; however, the currently published literature comprises only retrospective or prospective observational studies and randomized controlled results are not yet available but first study results in this respect are expected within the next 2–3 years. [ABSTRACT FROM AUTHOR]

Depending on the fracture pattern and soft tissue mantle involvement, clavicle fractures can be treated surgically or non-operatively. Historically, displaced fractures of the clavicle shaft in adults have been treated non-operatively. However, the nonunion rate after non-operative therapy seems to be higher than reported in the past. Additionally, publications reporting better functional outcomes after surgical therapy are accumulating. The current literature suggests that primary surgical stabilization, especially of displaced fractures, provides more rapid functional exercise treatment and thus earlier physical recovery than nonoperative therapy. Individualized treatment is suggested, with careful consideration of the advantages and disadvantages of each therapeutic approach and patient preferences. [ABSTRACT FROM AUTHOR]

Over the past 5 years both media and scientific interest has surged regarding the disorder myalgic encephalomyelitis and chronic fatigue syndrome (ME/CFS), not least because of the clinically similar manifestation in long COVID or post-COVID. In this review we discuss the process of clinical diagnosis and randomized controlled therapeutic studies on ME/CFS, and the similarities or differences to long COVID and post-COVID. So far, neither clear pathophysiologically causal nor therapeutic evidence-based results on ME/CFS have been identified in the many years of scientific research. Given the evident psychiatric comorbidity rates in patients with a diagnosis of ME/CFS, a psychosomatic etiology of this syndrome should be considered. Furthermore, a precise and reliable diagnostic classification based on stricter criteria would benefit both pathophysiological and therapeutic research. [ABSTRACT FROM AUTHOR]

Computer-assisted procedures are becoming increasingly more relevant in orthopedics and trauma surgery. The data situation on these systems has improved in recent years but still has a low level of evidence. In particular, data on short-term or medium-term results on the use of these procedures are currently available. These could show that improved precision and reproducibility of the surgical procedures can be achieved by the use of computer-assisted procedures. Nevertheless, there is still no recommendation in the current guidelines for routine use. [ABSTRACT FROM AUTHOR]

The article "Off-Label Use of Medicines in Children" deals with the application of medicines outside their approved range in children. Due to the lack of approved alternatives, off-label use in children is often necessary and represents the "state of the art". The contribution discusses the background and significance of off-label use in children, as well as the legal framework regarding permissibility, standard of care, informed consent, and reimbursement. It is pointed out that despite regulatory initiatives to promote drug development for children, many medicines still have to be used off-label due to a lack of approved drugs and data for the youngest age groups. [Extracted from the article]

Abstract: Objective: Germany´s federal government has decided to legalize the non-medical use and supply of cannabis, and presented core elements of the proposed regulation framework. Select core regulatory details are being assessed and commented on from a viewpoint of international scientific evidence and experiences in regard to cannabis legalization, with a principal focus on efforts and objectives of public health. Methods: Select summary and policy-analytical application of scientific evidence. Results: A substantial proportion of cannabis-related health problems is associated with the use of high-potency (THC) products; however, categorical THC-limits for legally available cannabis would overall be unlikely to reduce the total of these adverse outcomes, but rather retain many high-risk users involved in illegal supply systems. The minimum legal age of 18 years for legal cannabis appears to primarily reflect political considerations, and does not necessarily reflect optimal health or social protection efforts for young users; notwithstanding, cannabis use among youth will likely remain high. A cross-substance, public-health-oriented integration of regulatory restrictions with those for other substances (e. g., alcohol) would make sense. Driving under cannabis impairment is relatively common, and increases the risk for related injury and death, and consequentially results in substantial burden of disease; its control requires targeted education and deterrence measures. Cannabis legalization is generally difficult to reconcile with seminal international (e. g., UN) conventions; rather, it should be used as impetus to advocate for fundamental reforms of these treaties on the basis of public health principles and their protection. Conclusions: There are no golden recipes for the regulations for cannabis legalization in Germany; some of its core objectives will only be achievable by way of compromise approaches, which may need to be adjusted depending on outcomes experienced. Once implemented, Germany will be able to offer valuable data on cannabis legalization as a policy option, for which systematic and comprehensive process and outcome monitoring will need to be conducted. [ABSTRACT FROM AUTHOR]

Background: Lesions of the extracranial carotid artery are the cause of 10–15 % of all cases of cerebral ischemia. The aims of the updated S3 guidelines are evidence-based and consensus-based recommendations for action on comprehensive care of patients with extracranial carotid stenosis in Germany and Austria. Methods: A systematic literature search (1990–2019) and methodical assessment of existing guidelines and systematic reviews were carried out. Consensus answers to 37 key questions with evidence-based recommendations. Results: The prevalence of extracranial carotid stenosis is approximately 4% and increases after the age of 65 years. The most important examination method is duplex sonography. Randomized controlled studies (RCT) have shown that carotid endarterectomy (CEA) of an asymptomatic 60–99% carotid artery stenosis reduces the absolute risk of stroke (absolute risk reduction, ARR) within 5 years in comparison to drug treatment alone by 4.1%. Due to an improved pharmaceutical prevention of arteriosclerosis, the S3 guidelines recommend a prophylactic CEA of a 60–99% stenosis only for patients without an increased surgical risk. Additionally, one or more clinical or imaging results should be present, which indicate an increased risk of carotid-related stroke in the follow-up. For medium-grade (50–69 %) and high-grade (70–99 %) symptomatic stenoses the ARRs after 5 years are 4.6% and 15.6%, respectively. Systematic reviews of RCTs have shown that CEA is associated with a ca. 50% lower periprocedural risk of stroke compared to carotid artery stenting (CAS). There are no differences in the long-term course. The CEA is recommended for high-grade asymptomatic, medium-grade and high-grade symptomatic carotid stenosis as a standard procedure, alternatively CAS can be considered. For both procedures the periprocedural stroke rate/mortality during hospitalization should be a maximum of 2% (asymptomatic stenosis) or 4% (symptomatic stenosis). Conclusion: Both CEA and CAS necessitate a critical evaluation of the indications and strict quality criteria. Future studies should evaluate even better selection criteria for an individual, optimal, conservative, operative or endovascular treatment. [ABSTRACT FROM AUTHOR]

The scientifically founded surgical specialist discussion regarding the legal requirements for minimum volume numbers for diverse organ systems and selected surgical procedures as the basis of quality assurance and optimization of treatment is not new. Comprehensive and also reliable data from national and international studies are available for colorectal surgery, pancreatic surgery, esophageal surgery, liver surgery and gastric surgery. Recently, the raising of the minimum volume for complex esophageal interventions by the Federal Joint Committee (G-BA) in Germany from 10 up to 26 procedures per hospital and year, reignited the debate on this topic as well as the debate on centralization in the healthcare system in general. This decision seems to be scientifically well-justified from the perspective of political bodies and realizable in the practical implementation; however, from the perspective of physicians routinely involved in the corresponding highly complex procedures, there is a very much broader basis for discussion, which is only partially covered by a report of the Institute for Quality and Efficiency in the Healthcare System (IQWiG) as the foundation of the decision of the G‑BA. For the scientifically oriented surgical specialist society, in the first instance priority is given to the scientific evidence as the guiding principle. Nevertheless, aspects of the treatment reality cannot and should not be ignored. Therefore, the recommendations of the specialist society must be oriented not only to the quality of results but also to the realistic options for successful implementation in practice. Furthermore, questions of further education, the right of the patient to freedom of choice of the physician and preservation of the attractiveness of the occupational profile of surgeons are immanent topics for the surgical specialist society. [ABSTRACT FROM AUTHOR]

Retroperitoneal soft tissue sarcomas represent extreme challenges for interdisciplinary treatment teams. The sarcoma-specific experience of surgeons has the greatest impact on the survival of patients; however, too many patients still die despite optimal local treatment. The role of chemotherapy is undisputed only for patients with highly malignant bone sarcomas or rhabdomyosarcomas. For soft tissue sarcomas in adult patients, especially liposarcomas and leiomyosarcomas, the evidence situation is very unsatisfactory. This overview article discusses the complex data situation and controversial aspects that are relevant for current treatment decisions in interdisciplinary treatment teams. [ABSTRACT FROM AUTHOR]

Background: The "Cannabis as Medicine" Act (Gesetz "Cannabis als Medizin") has permitted the medical use of cannabis preparations under certain conditions since March 2017. It does not specify certain restrictive indications. Since its inception, the volume of prescriptions for cannabinoid-containing drugs skyrocketed. Whether this reflects an actual improvement in health care is controversial. Search method: This text is based on the clinical article "Cannabinoid-containing medicines" in Deximed (www.deximed.de), an online handbook for family physicians (FPs). For this article, sources, identified by selective literature research, were taken into account, including publications of the German Drug Commission, the comprehensive narrative review "Cannabis-Report" and available guidelines. Main Messages: Only in a few indications medical effectiveness of cannabis preparations has been proven, and only few finished medical products are available. In most cases, the prescription is a nolabel use. The most common prescription indication is chronic pain. The volume of prescriptions and associated costs are high despite poor evidence base. The highest costs are caused by the prescription of cannabis flowers and preparations thereof. About half of the costs arise from prescriptions by general practitioners. Conclusions: The prescription rates show that cannabinoid treatment is seen as a GP task. In order to proceed in an evidence-based and well-informed manner, sufficiently large randomized controlled trials, comprehensive early assessments by the Federal Joint Committee (Gemeinsamer Bundesausschuss), and more precise legal requirements and restrictions on use are needed. [ABSTRACT FROM AUTHOR]

Learning is indeed very individual, even personal, very independent, and proceeds quite stubborn and self-willed, always remains self-responsible. On the other hand, some eloquent convictions and tips for successful learning, as well as ideas and advice for the necessary teaching, are strange, even peculiar—and turn out to be myths that do not stand up to a logical-rational and evidence-based examination. A (non-systematic) narrative review [ABSTRACT FROM AUTHOR]

In recent years, knowledge about prearthrotic deformities of the hip joint and their treatment has grown significantly. Femoroacetabular impingement (FAI) is now considered a major prearthrotic deformity and cause of up to 50 % of all osteoarthritis hip disease. Treatment for FAI syndrome can be conservative therapy, physical therapy or surgery. Among surgical procedures, hip arthroscopy has established itself as the gold standard, but high-quality studies have been lacking for a long time. Randomized controlled trials (RCT) now show that hip arthroscopy leads to a significant improvement in symptoms and is significantly superior to physiotherapy alone, exceeding the minimum clinically important difference. Wether the improvement in hip morphology associated with surgical correction also reduces the risk of osteoarthritis in the long-term cannot yet be answered from the current data. Younger patients with FAI syndrome, positive clinical tests and appropriate radiological findings without significant degeneration of the joint should be advised about the possibility of arthroscopic correction and its superiority in outcome as part of the shared decision-making. [ABSTRACT FROM AUTHOR]

Modern surgery is currently undergoing a significant change in the sense of the introduction of modern technologies and innovative techniques. Robotic-assisted surgery and modern techniques of visualization confront surgery with unprecedented challenges with respect to possible and meaningful areas of application for these innovations. If an innovation is not to remain only an interesting singularity as proof of feasibility and a sign of unchecked progress but is to have a fixed place within the framework of standardized treatment processes, firm regulations are required which flank the path from innovation to introduction into clinical practice. This overview article critically examines the deficits of the currently practiced models of introducing new technologies into the clinical practice and discusses new aspects that can improve the introduction of innovations with particular respect to patient safety. [ABSTRACT FROM AUTHOR]

Background: Due to the necessity for lifelong treatment, high costs for the healthcare system and changes in role expectations of patients towards physicians, multiple sclerosis (MS) is an important topic in healthcare research. Objective: The aim of this review is to provide an overview of the current study situation in Germany in 2020 on utilization of outpatient medical resources and shared decision making in patients with MS. Material and methods: For this review a literature search was carried out in PubMed and other extended sources in order to identify and present relevant publications. Results: There are only a few studies on the utilization of outpatient medical resources by patients with MS in Germany. The highest values for utilization were found for general practitioners, family physicians and neurologists whereas urologists were less frequently involved. The values for the utilization of services provided by physiotherapists greatly differed between the studies. Several studies using different approaches to shared decision making in Germany were identified and summarized. An important prerequisite for shared decision making is an adequate knowledge on the side of the patients. Conclusion: Differences in the utilization of outpatient resources by MS patients in Germany can be explained by methodological differences and limitations of the individual studies. The use of shared decision making by MS patients is demanded by various parties but so far there is little evidence for a positive effect on the disease. [ABSTRACT FROM AUTHOR]

Since the first publication of the guideline in 2012, which included critically reviewed evidence up to 2010, several hundred articles with new evidence were published and some topics of the clinical consensus needed to be reconsidered. Therefore, it was urgently necessary to revise the guideline to bring them up to date. In this article important revisions and updates are presented and the chances and limitations of the development of the guidelines and their implementation are discussed. [ABSTRACT FROM AUTHOR]

Background: Healthcare research in the living environment is focused on the scientific investigation of care, which is delivered in the personal environment of those affected by diseases. Objective: Presentation of the healthcare policy starting position, content and evidence of forms of care by which treatment focuses on the living environment of affected persons. Presentation of the RECOVER model, by which these forms of care are integrated and coordinated in a care model. Material and methods: Literature search on "care or treatment models" and "psychiatric disease" over the last 10 years. Results: Many experts are calling for the introduction of integrated and coordinated care as well as the digitalization of the healthcare system as essential future solutions. Evidence-based forms of care, which have a main focus on the living environment of those concerned, play an important role here. These include, for example early diagnosis and treatment of psychoses (early psychosis services, EPS), crisis resolution team (CRT), assertive community treatment (ACT), supported employment (SE) and e‑mental health. With the exception of CRT, which can be financed as a hospital ward equivalent treatment according to §§ 39 and 115d (German Social Code V, SGB V), many of these treatment models are not yet part of standard care in Germany. In an integrated and coordinated care system these components work together in a meaningful and coordinated manner in defined care processes. This approach is currently being tested using the so-called RECOVER model, a severity level, evidence-based and cross-sectoral coordinated care model, where implementation, testing and transfer from 2017–2020 will be promoted by the Innovation Fund of the Joint Federal Committee (G-BA). [ABSTRACT FROM AUTHOR]

Im ersten Teil dieses Aufsatzes werden einige der Strategien, mit deren Hilfe Atheisten unverdiente Privilegien für ihre Position reklamieren, analysiert. Insbesondere wird dabei auf den Zusammenhang zwischen dem Evidentialismus und der Vorstellung eingegangen, dass der Atheismus die natürliche Ausgangsposition ist („presumption of atheism", Anthony Flew). Zudem wird untersucht, inwiefern die Ausschaltung des Agnostizismus als dritte Option zwischen Theismus und Atheismus zur diskursiven Privilegierung des Atheismus beiträgt (bei Paul Cliteur). Im zweiten Teil wird der Evidentialismus als kontextabhängige Begründungstheorie rekonstruiert und das (A)theismusproblem im Handlungs- statt im Erkenntniskontext situiert. Dadurch werden einseitige Verteilungen der Begründunglast vermieden, vor allem der atheistische Versuch, der Theistin die volle Begründungslast aufzubürden und gleichzeitig den Atheisten von allen Begründungslasten zu befreien. Dadurch kann der Diskurs um das (A)theismusproblem ohne die Zuschreibung unverdienter Privilegien rekonstruiert werden. Summary: In the first part of this article, some strategies are analyzed with the help of which atheists attempt to claim unearned cognitive privileges for their position. In particular, the connection between evidentialism and the 'presumption of atheism' (Anthony Flew) is scrutinized. In addition, Paul Cliteur's strategy to discredit agnosticism as a viable third option between theism and atheism in order to privilege atheism is investigated. In the second part of this article, evidentialism is reconstructed as being a context-dependent doctrine and the issue of (a)theism is treated under action-theoretical rather than epistemological parameters. As a result, the suggestion that the theist alone has the duty to legitimate her position while the atheist does not have any comparable duty is rejected and the issue of (a)theism is reconstructed without unearned cognitive privileges. [ABSTRACT FROM AUTHOR]

Anterior cruciate ligament (ACL) ruptures are the second most common sports injury after ankle injuries and most commonly lead to surgical treatment compared to all sports injuries. Rupture of the ACL is accompanied by increased anteromedial rotational translation of the lower leg relative to the upper leg. The consequence is a subjective sense of instability as well as an objective instability in clinical testing. The ACL reconstruction procedure has become the gold standard of surgical treatment. Despite the substantial literature available, there is controversy regarding the timing of the operation, techniques of surgical treatment, choice of suitable graft and fixation. Based on the current literature, this article aims to demonstrate the evidence of these points and to provide guidance on the optimal treatment of each individual patient considering the individual context factors. [ABSTRACT FROM AUTHOR]

Teacher education utilizes the scientific construct of evidence for decisions on the design of teacher trainings. While the relationship between diagnostic knowledge and positive attitudes towards inclusive teaching is widely accepted, the available evidence is constrained by many factors. We discuss the conditions of constructing evidence in teacher education and show typical errors of classical correlation analyses. Our analyses are based on a quasi-experimental study with 63 pre-service teachers, who learned how to diagnose students either with problem-based learning or with instruction-based learning. Applying an innovative statistical method that allows for calculating growth-curve models with small sample sizes, we show that a growth in diagnostic knowledge can correlate with a growth in positive attitudes towards inclusive teaching. In the discussion we focus on the meaning of the results for the transition of pre-service teachers into teaching. [ABSTRACT FROM AUTHOR]

Hintergrund: Pflanzliche Arzneimittel werden in Deutschland traditionell sehr häufig genutzt. Vor allem in der Selbstmedikation stellen sie eine wichtige Therapieoption dar.Methodik: Aktuelle systematische Übersichtsarbeiten und Metaanalysen wurden hinsichtlich der Evidenz phytotherapeutischer Arzneimittel bei ausgesuchten psychischen Erkrankungen ausgewertet und zusammengefasst.Ergebnisse: Abgesehen von Johanniskraut bei Depressionen ist die Evidenzlage für kein Phytopharmakon in der Psychiatrie bisher überzeugend.Schlussfolgerung: Aufgrund der vielversprechenden Wirkungen und dem niedrigen Nebenwirkungspotenzial in den vorhandenen Studien sind weitere randomisiert kontrollierte Studien (z. B. für Passiflora incarnata, Rhodiola rosea oder Lavendula officinalis) jedoch durchaus indiziert. [ABSTRACT FROM AUTHOR]

Hintergrund: Der Mini-gastric-Bypass/One-anastomosis-gastric-Bypass (MGB/OAGB) war im Jahr 2017 mit 1044 Eingriffen (13,9 % der Gesamtoperationen, StuDoQ|MBE) der dritthäufigste operative Eingriff für Adipositas in Deutschland.Ziel der Arbeit: Diese Analyse soll die aktuelle Evidenz des MGB/OAGB und die historische Evidenz zur Einschlingenrekonstruktion wiedergeben.Material und Methoden: Es erfolgte eine systematische Literaturanalyse in der elektronischen Datenbank MEDLINE via PubMed und im Studienregister Clinicaltrials.gov. Wir fanden 35 relevante Artikel: 19 retrospektive Studien, 8 retrospektive Vergleichsstudien, 2 Übersichtsarbeiten, 3 systematische Reviews und Metaanalysen und 3 prospektiv randomisiert kontrollierte Studien. In Clinicaltrials.gov waren 8 prospektiv randomisierte Studien registriert.Ergebnisse: Nach MGB/OAGB betrug die 30-Tage-Mortalität 0-0,9 %, interventionspflichtige Komplikationen traten bei einer perioperativen Gesamtmorbidität von 3,2-10,8 % zu 0,8-7 % auf. Der „total weight loss“ betrug 31-38 % nach einem und 23-32 % nach 5 Jahren. In allen Arbeiten zeigte sich eine positive Wirkung auf die metabolischen Begleiterkrankungen. Studien zu harten Endpunkten wie „Endorganschäden bei Diabetes“, „Reduktion kardiovaskulärer Ereignisse“ und eine Verlängerung des Überlebens existieren bislang nur für den Roux-Y-Magenbypass.Diskussion: Der MGB/OAGB hat eine geringe perioperative Komplikationsrate und bietet kurzfristig Vorteile bezüglich des Gewichtsverlusts und des antidiabetischen Wirkungsgrades im Vergleich zu den etablierten Standardverfahren Roux-Y-Magenbypass und Schlauchmagen. Der Stellenwert des biliären Refluxes und einer damit verbundenen Möglichkeit der Entartung im Langzeitverlauf ist derzeit unklar. Bisher ausstehende Ergebnisse der registrierten prospektiv randomisierten Studien werden in Zukunft eine bessere Evidenz bieten können. [ABSTRACT FROM AUTHOR]

Zahlreiche Einzelstudien und Metaanalysen zeigen, dass psychotherapeutische Interventionen bei Menschen mit bipolaren Störungen den Krankheitsverlauf positiv beeinflussen können. Der Artikel gibt eine Übersicht über die Entwicklung der Psychotherapie für Menschen mit bipolaren Störungen, es werden die nach den aktuellen Leitlinien evidenzbasierten Verfahren mit ihren Wirkprinzipien vorgestellt, sowie neuere Entwicklungen der Psychotherapieforschung in diesem Feld skizziert. [ABSTRACT FROM AUTHOR]

Abdominal and thoracic fistulas can be caused by the trauma itself, the treatment or its complications. Successful treatment is achieved by fistula prevention, anticipation and rapid diagnostics with a treatment plan considering all treatment options. Determining factors for treatment are the origin and endpoint of the fistula, affected organs, tissue condition, additional trauma, chronic diseases, timeline, previous treatment, institutional experience and the patient's general condition. Criteria and indications for conservative, interventional and surgical treatment are demonstrated and case examples are presented. Scientific evidence is mainly retrospective and determined by experience. The interdisciplinary treatment team consists of trauma surgery, specialized surgical disciplines, intensive care specialists and interventional specialists. [ABSTRACT FROM AUTHOR]

The idea of a decided scientific orientation of teacher education and educational practice is not new. However, laying claim to the concept of evidence is relatively new. This also holds true for the current focus on evidence-based medicine, which in the same breath is seen in a pioneering role considering issues of evidence-based practice. The concept of evidence is enigmatic and brings about several problems. In addition, there are different paradigms with respect to the interpretation and application of this concept. Compared to the predominating American version, the prevalent evidence perspective in Germany is characterized by a liberal and plural orientation concerning research methods. Evidence-based practice is rather considered as a special case of evidence-oriented or evidence-informed practice. As a consequence, more evaluative and reflective functions of pedagogical and psychological evidence, which build the focus of the present contribution, are accentuated with respect to educational practice. However, the application of scientific knowledge in educational practice faces problems, which are caused not least by the questionable quality of the scientific knowledge base. In addition, fitting and transfer problems are inevitable. Even the elaborated technological conception of psychology by Theo Herrmann was not able to overcome these problems. All the more, evidencebased educational practice makes extraordinarily high demands on teachers with respect to their educational research competence as well as their competences to integrate scientific knowledge and experience-related knowledge. These competences have to be fostered systematically already in teacher education at university. [ABSTRACT FROM AUTHOR]

Abdominal and thoracic fistulas can be caused by the trauma itself, the treatment or its complications. Successful treatment is achieved by fistula prevention, anticipation and rapid diagnostics with a treatment plan considering all treatment options. Determining factors for treatment are the origin and endpoint of the fistula, affected organs, tissue condition, additional trauma, chronic diseases, timeline, previous treatment, institutional experience and the patient's general condition. Criteria and indications for conservative, interventional and surgical treatment are demonstrated and case examples are presented. Scientific evidence is mainly retrospective and determined by experience. The interdisciplinary treatment team consists of trauma surgery, specialized surgical disciplines, intensive care specialists and interventional specialists. [ABSTRACT FROM AUTHOR]

This study examines how evidence is used differently in argumentative discourse compared to individual arguments. Applying a 1 x 2 crossover study design, 37 secondary school students were asked either to discuss a social issue with their partner before individually writing an essay outlining their opinion or, vice versa, first to discuss and then to write. As background information, they were provided with pieces of evidence with different levels of quality. Dialogs and essays were analyzed regarding (a) the type of evidence and (b) the way evidence was used. Results showed that in their essays students referred more often to the pieces of evidence provided to them (shared evidence). In contrast, they used evidence more often to address the opposing viewpoint in dialogs by incorporating it in a more elaborated (clearer) line of reasoning. Findings suggest that dialogues are a more effective tool than individual writing production, and the study provides first hints regarding how to design curricula that will encourage students to use evidence in a more sophisticated way in their argumentation. [ABSTRACT FROM AUTHOR]

The majority of recommendations in the current S3 guideline on the diagnosis and treatment of gastric carcinoma are based on good clinical practice and lack supporting randomized studies. With the development of endoscopic resection and multimodal treatment concepts, pretherapeutic tumor staging has gained in importance. However, the accuracy of present imaging modalities is still limited with a tendency towards overstaging of locally advanced tumors. Extended lymph node dissection cannot be recommended in cases with advanced lymph node involvement. In cardiac cancer retroperitoneal lymphatic spread to the left renal vein is an early event and should thus not be classified as stage IV disease. In cases of intra-abdominal gastrectomy a pouch reconstruction should be considered in cases with a good overall prognosis. Subgroup analyses indicate a differential therapeutic effect of the established perioperative chemotherapy depending on the location of the primary tumor. There is also good evidence for an additional beneficial effect of radiotherapy in combination with chemotherapy. [ABSTRACT FROM AUTHOR]

Bipolar disorders are severe psychiatric disorders with extensive individual and health economic consequences. Starting in 2007 the first German evidence and consensus based guideline for diagnostics and treatment of bipolar disorders was developed which holds the potential of increasing confidence of therapists, patients and relatives in the decision-making process and improving healthcare service experiences of patients and relatives. Apart from recommendations for diagnostics and treatment the guidelines provide those for trialogue action, knowledge transfer and self-help and for strategies for healthcare provision of this complex disorder. In the present article the methodology and essential recommendations are outlined and complemented in specific topics by corresponding articles in this special issue. Due to restrictions of the length of this presentation there is the need to refer to the comprehensive version of the guidelines at several points also regarding a detailed discussion of the limitations. [ABSTRACT FROM AUTHOR]

The current S3 guidelines on the diagnosis and treatment of gastric carcinoma including those of the esophagogastric junction describe optimal clinical practice based on a high level of evidence and expert consensus from different medical disciplines. Endoscopy and performance of multiple biopsies is the standard approach to detect malignant tumors in the upper gastrointestinal tract. Further diagnostic procedures are necessary to evaluate the tumor stage. With the exception of mucosal carcinomas, surgical therapy is the cornerstone of curative treatment in all potentially resectable stages. In locally advanced carcinomas perioperative chemotherapy should be carried out and in high-seated tumors preoperative radiochemotherapy might be an alternative option. Palliative surgical resection should be avoided in disseminated asymptomatic stages. In a palliative situation complications of the tumor should primarily be treated by interventional or conservative procedures. [ABSTRACT FROM AUTHOR]

In numerous situations stroke physicians face a lack of evidence during their daily practice. In this report the authors address some of the difficult treatment decisions encountered in acute therapy and secondary prevention. Examples include off-label thrombolysis and prevention in high-risk situations. The available data from trials and registries are discussed, and personal views and recommendations are expressed. [ABSTRACT FROM AUTHOR]

Results from recent studies have questioned the application of beta-receptor blockers for reduction of morbidity and mortality during the perioperative period. This holds true especially for patients with no or only low cardiac risk. Although beta-receptor blockade was a form of standard therapy at the end of the 1990s, data today show no clear evidence for such a therapy not even in patients at risk for cardiac events. At least in patients with low risk the initiation of beta-receptor blockade during the perioperative period might lead to side-effects, thereby increasing morbidity and mortality. [ABSTRACT FROM AUTHOR]

The Chronic Care Model (CCM) is an organizational approach to caring for people with chronic disease in a primary care setting. The system creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive practice team. The CCM identifies essential elements of a health care system that encourage high-quality chronic disease care: the community; the health system; self-management support; delivery system design; decision support, and clinical information systems. [ABSTRACT FROM AUTHOR]