[Risks of the stay at home policy during the COVID-19 pandemic]. / Risiken der "Stay at home"-Politik im Rahmen der COVID-19-Pandemie.

The measures to control the COVID-19 pandemic have far-reaching sequelae for the German healthcare system and our citizens. Since the implementation of the pandemic measures with a nationwide lockdown on 22 March 2020, so far some relevant aspects have already been described. This overview article gives a more detailed description of some aspects relevant for vascular medicine, e.g. emergency treatment, increase of the cardiovascular risk due to social distancing and the risk of venous thromboembolisms.

Re-irradiation for recurrent glioblastoma multiforme: a critical comparison of different concepts.

PURPOSE: Purpose of this study was to investigate outcome and toxicity of re-irradiation for recurrent primary glioblastoma (rGBM). We evaluated a group of patients with rGBM and identical primary treatment comprising adjuvant radiotherapy (30â€¯× 2 Gy) with concurrent temozolomide (TMZ). METHODS: In this retrospective study of 46 patients, all received adjuvant or definitive normofractionated radiotherapy to a pretreated area, some with concurrent chemotherapy. Impact of different clinical, histological, or epidemiological factors on survival and radiation toxicity was reviewed. RESULTS: Of 46 patients, 40 completed the intended therapy. Overall survival (OS) was 20 months (range 6-72 months). Overall survival and progression-free survival after re-irradiation (OS2 and PFS2) were 9.5 and 3.4 months (range 2-40 and 0.7-44 months). Simultaneous systemic therapy improved PFS2 and OS2 (4.3 vs. 2.0, p < 0.001 and 12 vs. 4 months, p = 0.13, respectively). Therapy with TMZ or bevacizumab improved PFS2 vs. nitrosureas (6.6 vs. 2.9, p = 0.03 and 5.1 vs. 2.9 months, p = 0.035, respectively). TMZ also improved PFS2 and OS2 vs. all other systemic therapies (6.6 vs. 4, p < 0.001 and 17 vs. 10 months, p = 0.1). In a subgroup analysis for patients with methylation of the MGMT promoter, doses of >36 Gy as well as TMZ vs. no systemic therapy improved PFS2 (p = 0.045 and p = 0.03, respectively). 27.5% of all patients had no acute toxicity. Three patients with acute and four patients with late grade 3 toxicities were reported. CONCLUSION: Normofractionated radiotherapy is a feasible option for rGBM with a good toxicity profile. Simultaneously applied systemic therapy was associated with improved outcome. For MGMT promoter-methylated histology, higher radiation doses improved survival.

[Acute deep vein thrombosis-modern diagnostics and treatment]. / Akute Beinvenenthrombose ­ moderne Diagnostik und Therapie.

Acute deep pelvic vein thrombosis (DVT) is usually a non-fatal disease that causes lifelong damage. In the case of clinical suspicion of DVT, D­dimer determination and/or imaging must be performed. If a timely diagnosis is not possible, anticoagulation should be started. The focus of treatment is the safety of the patient. All studies on thrombus-eliminating procedures, such as thrombolysis, operative open thrombectomy and endovascular revascularization, did not show any advantages over pure anticoagulation and are associated with specific risks. The minimum duration of anticoagulation is 3 months. Thereafter, the decision of prolonged anticoagulation must be made individually for each patient. Compression therapy is an integral part of the treatment of acute TVT in Germany, even the evidence for its effectivenes with respect to the prevention of post-thrombotic syndrome is low.

[Recognition and correct classification of pressure ulcers: a position paper]. / Dekubitus erkennen und richtig klassifizieren: ein Positionspapier.

BACKGROUND: Pressure ulcers comprise serious skin and tissue damage. The correct diagnosis and classification into different categories is often difficult in daily practice. QUESTION: What procedure can be recommended to correctly diagnose and classify pressure ulcers in practice? MATERIALS AND METHODS: The society Initiative Chronische Wunden (ICW) e. V. established a group of experts who developed practical recommendations for the diagnosis and classification of pressure ulcers based on the current literature and their own expertise. RESULTS: Pressure ulcers should only be diagnosed if skin and/or tissue damage is most likely due to prolonged pressure or pressure associated with shear forces. A complete anamnesis must be performed to detect periods of previous prolonged immobility. Pressure ulcers are usually located at typical predilection sites. For category I and "suspected deep tissue damage" the tissue damage occurs under (initially) intact skin. However, the diagnosis is uncertain and the classification should be made later. The category II pressure ulcer is usually an exclusion diagnosis. The categories III and IV are pressure ulcers in the proper sense. As long as the distinction between category III and IV is not possible, the lower category should be coded. CONCLUSIONS: Currently, a relevant classification should be used uniformly for the respective setting. In accordance with the clinical picture, a most suitable diagnosis is to be made. It does not matter which classification system is used. The future WHO ICD-11 version will allow better classification of pressure ulcers.

[Compression therapy of chronic leg ulcers : Practical aspects]. / Kompressionstherapie des chronischen Ulcus cruris : Praxisrelevante Aspekte.

Compression therapy, together with modern moist wound treatment, is the basis for a successful conservative treatment of patients with chronic leg ulcers. In clinical practice, it is often the patients themselves who apply compression therapies. Many of the mostly elderly patients, however, are not able to reach their legs and feet due to movement restrictions, such as arthritis, arthrosis and even obesity. An adequate compression therapy also requires extensive experience and regular training. In practice only the minority of patients can perform bandaging well and therefore this should not be recommended. Self-management with do-it-yourself medical devices will become more and more important in the future. In addition to the psychological factors, cost aspects and demographic change, an expected lack of qualified nursing staff due to the number of elderly patients who are potentially in need of care means that self-management is becoming increasingly more important. For the essentially important compression therapy of patients with chronic leg ulcers, there already exist various therapy options. The needs, preferences and abilities of the patients concerned can be considered when selecting the appropriate system. Particularly for the self-management of compression therapy, adaptive compression bandages are suitable for patients with leg ulcers during the initial decompression phase and ulcer stocking systems in the subsequent maintenance phase.

Diagnosis and treatment of chronic wounds: current standards of Germany's Initiative for Chronic Wounds e. V.

The diagnosis and treatment of patients with chronic wounds is an enormous challenge in various disciplines of medicine. These very complex processes usually involve several experts of different medical specialties with varying educational backgrounds. A necessary basis for consistent communication and documentation is the use of unambiguous nomenclature. Therefore, the board of the German wound association, Initiative for Chronic Wounds (ICW) e.V., has started to define various terms and procedures. An easy to remember algorithm, in the form of the ABCDE rule, has been developed for the structured diagnosis of chronic wounds. The successful therapy of chronic wounds is then based on the causal treatment of the underlying, pathophysiological relevant diseases. M.O.I.S.T. a concept which helps health professionals in the systematic approach to the local treatment of patients with chronic wounds, in conforming to the most up-to-date scientific knowledge. By using consistent definitions and standards in wound care, it is possible to optimise current diagnostic and treatment strategies as well as to make them more easily understandable.

Analysis of the German DRG data for livedoid vasculopathy and calciphylaxis.

BACKGROUND: Livedoid vasculopathy and calciphylaxis are rare skin disorders. Large cohorts of patients have been missing so far for detailed analysis. PATIENTS AND METHODS: Data from diagnosis-related groups (DRGs) of hospitalized cases of livedoid vasculopathy (ntotal = 1357) and calciphylaxis (ntotal = 699) were analysed for the years 2008-2013 concerning sex, age and frequency of diagnosis. To avoid deviations to non-relevant secondary diagnosis and due to changes in ICD-10 indices, we selected the two most recent available years 2013 and 2014 for evaluation of the accompanying diagnoses for both, livedoid vasculopathy (n = 519) and calciphylaxis (n = 324). Those were additionally evaluated as possible comorbidity. RESULTS: The male-female ratio for livedoid vasculopathy was 2.1:1. Patients older than 45 years comprehended 74.7% of all patients with peaks between the ages of 45-50 and 70-75. Livedoid vasculopathy patients suffered from cardiovascular and renal diseases. Coding of coagulation disorders was found rarely in our analysis. For calciphylaxis, we calculated a male-female ratio of 1.7:1. Most of the patients were at an age between 65 and 80 years. Diagnosis at an age under 35 years was rare. In general, most calciphylaxis patients showed end-stage renal disease with need of dialysis and presented with the resulting complications. CONCLUSIONS: Our data analysis shows relevant comorbidity and cofactors of these rare diseases like livedoid vasculopathy and calciphylaxis in Germany by a large number of cases.

Disproportional increase of pulmonary embolism in young females in Germany: trends from 2005 to 2014.

We analysed the number of pulmonary embolism (PE) in young females aged 10-39 years in the period from 2005 to 2014 in Germany to see any trends that possibly may reflect some influences of newer oral contraceptives. Detailed lists of all hospitalized cases with the principal diagnosis PE coded as I26 in the years 2005-2014 were provided by the Federal Statistical Office. In males, the absolute number of all hospitalized cases with the principal diagnosis PE increased from 16,066 in 2005 to 25,364 in 2014 (rate +57.8%) and in females from 21,548 to 29,433 (rate +36.5%). The annual differences in PE between males and females decreased from 5482 to 4069 (-26%) in this period. In the age group of 10-39 years the absolute number of all hospitalized male cases increased from 1023 in 2005 to 1276 in 2014 (+24.7%) and in females from 1341 to 1949 (rate +45.3%). Thus in contrast to the overall trend the annual difference in PE rose gradually by 112% (from 318 to 673) from 2005 to 2014. Our ecologic nationwide analysis of hospitalization rates for PE shows that the annual differences between males and females cases hospitalized with the principal diagnosis PE in general decreased, but increased in the age group of 10-39 years in the last decade.

[Compression therapy in leg ulcers]. / Kompressionstherapie des Ulcus cruris.

Compression therapy is well-tried treatment with only few side effects for most patients with leg ulcers and/or edema. Despite the very long tradition in German-speaking countries and good evidence for compression therapy in different indications, recent scientific findings indicate that the current situation in Germany is unsatisfactory. Today, compression therapy can be performed with very different materials and systems. In addition to the traditional bandaging with Unna Boot, short-stretch, long-stretch, or multicomponent bandage systems, medical compression ulcer stockings are available. Other very effective but far less common alternatives are velcro wrap systems. When planning compression therapy, it is also important to consider donning devices with the patient. In addition to compression therapy, intermittent pneumatic compression therapy can be used. Through these various treatment options, it is now possible to develop an individually accepted, geared to the needs of the patients, and functional therapy strategy for nearly all patients with leg ulcers.

Topical oxygen wound therapies for chronic wounds: a review.

UNLABELLED: Chronic wounds are an increasing problem in our ageing population and can arise in many different ways. Over the past decades it has become evident that sufficient oxygen supply is an essential factor of appropriate wound healing. Sustained oxygen deficit has a detrimental impact on wound healing, especially for patients with chronic wounds. This has been proven for wounds associated with peripheral arterial occlusive disease (PAOD) and diabetic foot ulcers (particularly in combination with PAOD). However, this is still under debate for other primary diseases. In the past few years several different new therapeutic approaches for topical oxygen therapies have been developed to support wound healing. These tend to fall into one of four categories: (1) delivery of pure oxygen either under pressurised or (2) ambient condition, (3) chemical release of oxygen via an enzymatic reaction or (4) increase of oxygen by facilitated diffusion using oxygen binding and releasing molecules. In this review article, the available therapeutic topical oxygen-delivering approaches and their impact on wound healing are presented and critically discussed. A summary of clinical data, daily treatment recommendations and practicability is provided. DECLARATION OF INTEREST: J. Dissemond received an honorarium for lectures, advisory boards and/or clinical studies from the following companies: 3M, B. Braun, BSN, Coloplast, Convatec, Draco, Hartmann, KCI, Lohmann&Rauscher, Medoderm, Merz, Sastomed, Systagenix, UCB-Pharma, Urgo. K. Kröger received an honorarium for lectures, advisory boards and/or clinical studies from the following companies: Bayer, Sanofi, GSK, Hartmann, Sastomed, UCB-Pharma, Urgo. M. Storck received an honorarium for lectures for the following companies: KCI, Systagenix, and UCB-Pharma. A. Risse received an honorarium for lectures, advisory boards and/or clinical studies from the following companies: Bracco, Coloplast, Draco, Lilly Deutschland, NovoNordisk, Sastomed, Urgo. P. Engels received an honorarium for lectures, and consulting from the following companies: Sastomed, Oculus.

Venous thromboembolism in Germany: results of the GermAn VTE registry (GATE-registry).

BACKGROUND: Despite the existence of active prophylaxis strategies for patients at risk of venous thromboembolism (VTE), people still suffer from this disease. To establish the setting in which VTE occurs and how it can be prevented, a study was conducted aimed at analysing the circumstances surrounding VTE development. PATIENTS AND METHODS: In a nationwide study, 629 patients (54% female) with acute deep vein thrombosis (DVT) or pulmonary embolism (PE) were recruited consecutively at 17 centres (78.4% with DVT, 5.1% with PE, 16.5% with both). The physicians completed a standardised questionnaire together with the patients on the day the diagnosis was made, or a few days later. The following items were included: general information, circumstances that could increases VTE risk within the previous 6 weeks, action taken to prevent VTE within the previous 6 weeks, specific VTE risk factors. Patients were defined as being 'in a medical setting' if they had had contact with a physician within the 6-week period prior to VTE diagnosis. RESULTS: A total of 286 (45.5%) patients were classified in a medical setting, but 343 (54.5%) patients were not. Of those who were not in a medical setting within the last six weeks, 12.0% had returned from a journey and 15.5% had restricted mobility. Of those within a medical setting, only 80 (28.0%) patients had received heparin as prophylaxis. Thus, the largest group of patients with VTE today is not within a medical setting. The next largest group of patients were in a medical setting but received no heparin as prophylaxis. Those with a failed or inadequate use of prophylaxis represented the smallest group. DISCUSSION: More than 50% of those who have acute VTE are not being reached by our present day VTE prophylaxis strategies.

Pulmonary embolism in young people. Trends in Germany from 2005 to 2011.

OBJECTIVES: There is an ongoing discussion about the impact of hormonal contraception on the incidence of venous thromboembolism (VTE) in young women. Specific data of the significance of this problem and its changes in recent years in Germany are not available. Thus, we analyzed the incidence of VTE in hospitalized young patients and looked for gender-specific differences. PATIENTS AND METHODS: Detailed lists of all pulmonary embolisms (PE) coded as I26 and deep vein thrombosis (DVT) coded as I80 in patients aged 10 to 39 years hospitalized in the years 2005 to 2011 were provided by the Federal Statistical Office. RESULTS: Beginning at the age of 12-13 years girls have higher numbers of PE and DVT documented as principal diagnosis, as compared to boys. This gender-specific difference disappears at the ages of 32-33 years. The difference in total numbers of PE (as principal diagnosis) between women and men within this 20-year time span increased from 318 in 2005 to 606 in 2010 and decreased to 505 in 2011. Stratifying the cases of PE according to presence or absence of cor pulmonale, the analysis showed a specific increase of PE in young women without cor pulmonale within the period of seven years between 2005 and 2011. Similar changes could not be shown for DVT as principal diagnosis. CONCLUSION: The presented data from the German DRG statistics show a disproportionally higher increase of young women hospitalised for pulmonary embolism as principal diagnosis in recent years. The possible impact of hormonal contraception on this increase has to be further elucidated.

Thoracal, abdominal and thoracoabdominal aortic aneurysm.

AIM: Aortic aneurysm is a complex disease affecting males and females in a different way. We analysed gender specific differences in the abdominal (AAA), thoracal (TAA) and thoraco-abdominal (TA-AA) aortic aneurysm in patients hospitalized for aortic aneurysm (AAA) in Germany. METHODS: Detailed lists for all patients suffering from AAA, TAA or TA-AA documented in the DRG-System as principal diagnosis in the years 2010 were provided by the Federal Statistical Office. RESULTS: The total number of cases in males was 17,731. It was more than three time higher than in females with 4657. AAA were 6.2 time more frequent in males than in females, TAA and TA-AA only 1.6 and 1.5 times, respectively. The rates of ruptured aneurysms show a steep increase in the 9th and 10th decade which is more pronounced in females. In males there is an age dependent increase in the rate of endovascular treatment of TAA and AAA. There is no such trend in females. The rate for AAA even decreases with age. The same could be shown for more complex fenestrated or branched endoprotheses. In around 20% of all male cases with TA-AA such a design is used in the 7th to the 9th decade of life. In females such a rate is only reached in the 7th decade. In older females the rate stepwise decreased. CONCLUSION: There are gender specific differences in the rate of rupture and endovascular treatment of AAA, TAA and TA-AA in males and females in Germany. The reasons for these differences should be elucidated in order to prove whether these differences are due to actual gender specific requirements, or simply a lack of compatibility in awareness and devices.

[Innovative wound care--new studies to increase evidence]. / Innovative Wundversorgung--neue Studien zur Evidenzsteigerung.

BACKGROUND: Today numerous products for wound care are available. A research-based evidence on which the clinician can base its selection, is still missing. In the guidelines randomized controlled trials (RCTs) have been left out. METHOD: In the overview three current RCT with products for the treatment of chronically venous ulcers will be presented. RESULTS AND CONCLUSIONS: The pre-mentioned studies show, that it is possible to provide a basis for evidence-based treatment in wound healing. The effective value ofa wound treatment based on the costs and benefits must be defined by the health system. But products, for which data from randomized trials exist, should be evaluated in a different way to products, for which there are no such data.

Endovascular abdominal aneurysm repair: trends in Germany.

BACKGROUND: As a minimally invasive technique endovascular aneurysm repair (EVAR) reduces the risk of mortality and should be the preferred technique used in older patients. We analysed trends in endovascular and open surgical procedures in patients hospitalized for abdominal aortic aneurysm (AAA) in Germany. PATIENTS AND METHODS: We used national statistics (DRG statistics) published by the Federal Office of Statistics in Germany to calculate the incidence of patients hospitalised with ruptured (rAAA) and elective (eAAA) AAA. In addition, annual procedure rates of endovascular (EVAR) procedures were calculated. RESULTS: Incidence rates of eAAA per 100,000 males (females) showed a small increase from 2006 to 2007 but remained almost unchanged with 74.8 (8.8) in 2007 and 74.5 (9.8) in 2009. Incidence rates of rAAA per 100 000 males remained unchanged but showed a decreasing trend in females. The rate of people treated by EVAR increased form 2006 to 2009: in males from 24.0 % to 40.3 % and in females from 17.3 % to 31.0 %. In younger males (55 - 60 years) the increase in those who received EVAR was smaller (from 22.1 % to 33.9 %) than in older males (85 - 90 years) (from 20.4 to 41.6 %). Despite a clear increase in the use of EVAR from 2006 to 2009 there is only a small trend in reduction of the death rates which is more pronounced in rAAA. CONCLUSIONS: There has been a relevant increase in EVAR procedures for the treatment of AAA in Germany in recent years. Parallel to this increase of EVAR, aneurysm-related in-hospital deaths seem be declining slightly. A causal relationship between these trends remains to be proven.

[Carotid sinus massage - who is allowed to do it?]. / Carotis-Sinus-Massage - Wer darf sie anwenden?

Although carotid sinus massage (CSM) belongs to the basic knowledge of every physician, there are no universally valid and structured guidance on the nature of the implementation and application. We analyzed the existing guidelines and literature in light of who is allowed to perform CSM. In summary, there are two indications for CSM: As part of diagnostic tools to clarify underlying pathology of syncope CSM should be performed only by an experienced physician with ECG control and after sonographic exclusion of carotid atherosclerosis if no other explanations are reasonable. In case of supraventricular tachycardia CSM may be used by any physician without prior sonography of the carotids to terminate the tachycardia before any pharmacological strategies are performed.