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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]

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]

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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]

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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]

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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]

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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]

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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]

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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]

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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]

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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]

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In this article a brief version of the newly developed S3 guidelines on screening, diagnosis, therapy and follow-up of abdominal aortic aneurysms (AAA), which was developed under the auspices of the German Society of Vascular Surgery and VascularMedicine (DGG) is presented. In addition to the DGG, participating professional societies were the German Radiological Society (DRG), German Society for Angiology/Society for Vascular Medicine (DGA), German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), German Society for Ultrasound in Medicine (DEGUM), German Vascular League e.V., German Society for Interventional Radiology (DEGIR), German Society for Anesthesiology and Intensive Care Medicine (DGAI), German Society for Thoracic and Cardiovascular Surgery (DGTHG) and the German Society of Surgery (DGCH). The guidelines are based on a systematic literature search in Medline (PubMed) for the period from 1 January 2000 to 1 January 2017. Important publications from 2017 were also considered. The selection of evidence was made by a multilevel screening process. In addition to the evidence, other criteria were included in the assessment of the recommendation level, such as the consistency of the study results, the clinical relevance of the endpoints and effect sizes, the benefit-risk balance, the applicability of the study results to the patient target group and the care system, the feasibility of the recommendations in everyday life, patient preferences and ethical and legal considerations. All recommendations/findings were approved with strong consensus (approval of >95% of the participating professional societies/associations). Thus, the present text version of the S3 guidelines on AAA represents the view of all participating societies. [ABSTRACT FROM AUTHOR]

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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]

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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]

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This article summarizes the current study situation on treatment of asymptomatic carotid artery stenosis and discusses the evidence situation in the literature. The 10-year results of the ACST study have shown that in comparison to conservative treatment, carotid endarterectomy (CEA) has retained a positive long-term effect on the reduction of all forms of stroke. All multicenter randomized controlled trials comparing CEA with carotid artery stenting (CAS) and, in particular the SAPHIRE and CAVATAS studies, have in common that despite a basic evidence level of Ib, the case numbers of asymptomatic patients are too small for a conclusive therapy recommendation. In the overall assessment of the CREST study the resulting difference in the questionable endpoint of “perioperative myocardial infarction” in favor of the CAS methods, could not be confirmed for exclusively asymptomatic patients. In the long-term course of the CREST study, both methods were classified as equivalent, even when the 4‑year results of periprocedural and postprocedural stroke rates in the separate assessment of the asymptomatic study participants clearly favored the CEA. The results of the ACST-1 study showed an equivalent effect of both treatment methods with respect to all investigated endpoints; however, the unequal sizes of the groups in addition to the statistically insufficient case numbers put a question mark on the validity of the study results. The results of the ASCT-2 and CREST-2 studies are to be awaited, which also investigate the significance of “CEA versus CAS” (ASCT-2) and “CEA/CAS + best medical treatment (BMT) versus BMT alone” in only asymptomatic stenoses. The current S3 guidelines allow operative therapy to be considered in patients with a 60-99% asymptomatic carotid artery stenosis, because the risk of stroke is statistically significantly reduced. [ABSTRACT FROM AUTHOR]

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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]