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IntroductionPost-COVID-19 syndrome (PCS) is characterized by a wide range of symptoms, predominantly fatigue and exertional intolerance. While disease courses during the first year post infection have been repeatedly described, little is known about long-term health consequences.MethodsWe assessed symptom severity and various biomarkers at three time points post infection (3-8 months (mo), 9-16mo, 17-20mo) in 106 PCS patients with moderate to severe fatigue and exertional intolerance. A subset of patients fulfilled diagnostic criteria of myalgic encephalomyelitis/chronic fatigue syndrome (PCS-ME/CFS) based on the Canadian Consensus Criteria.ResultsWhile PCS-ME/CFS patients showed persisting symptom severity and disability up to 20mo post infection, PCS patients reported an overall health improvement. Inflammatory biomarkers equally decreased in both groups. Lower hand grip force at onset correlated with symptom persistence especially in PCS-ME/CFS.DiscussionDebilitating PCS may persist beyond 20mo post infection, particularly in patients fulfilling diagnostic criteria for ME/CFS.

Zusammenfassung Hintergrund Die Epistaxis ist ein häufiges Symptom in der Arztpraxis und assoziiert mit verschiedenen Komorbiditäten und Medikamenten, insbesondere Antikoagulanzien. Trotz ihrer Alltäglichkeit gibt es nur wenige Daten zur Häufigkeit ihres Auftretens und möglichen Risikofaktoren. Methoden Die Studie untersuchte anhand einer großen Patientenpopulation (AOK Niedersachsen) über 10 Jahre (2007–2016) die Versorgung von Epistaxis in Niedersachsen. Alter bei Diagnose, Begleitmedikation und Komorbiditäten wurden analysiert und die Prävalenz dargestellt. Ergebnisse 162.167 Versicherte der AOK Niedersachen wurden zwischen 2007 und 2016 aufgrund einer Epistaxis in 308.947 Fällen ärztlich vorstellig. Die meisten Patienten wurden ausschließlich ambulant behandelt (96,6 %). Über den Studienzeitraum stieg die Prävalenz um 21 % (Anstieg von 8,7 auf 9,3 pro 1000 Versicherte/Jahr) bei stabiler Prävalenz für stationäre Vorstellungen (0,2 pro 1000 Versicherte/Jahr). Die höchsten Prävalenzen fanden sich bei Personen bis 20 und über 80 Jahre. In 17,5 % aller Epistaxisfälle wurden Antithrombotika erfasst (9,5 % orale Antikoagulanzien). Über den Studienzeitraum konnte eine erhöhte Verschreibung von Antikoagulanzien (7,7 % in 2007 auf 11,8 % in 2016, insbesondere NOAK) dokumentiert werden. Schlussfolgerung Neben der arteriellen Hypertonie, dem männlichen Geschlecht sowie der typischen Altersverteilung bestand auch häufig eine Medikation mit Antikoagulanzien. Über den untersuchten Zeitraum zeigte sich eine Zunahme von Epistaxisfällen bei gleichzeitig ansteigender Verschreibungshäufigkeit von NOAK, nicht jedoch von schweren hospitalisationsbedürftigen Epistaxisfällen. Eine abschließende Beurteilung hinsichtlich eines möglichen kausalen Zusammenhangs muss in weiteren Studien untersucht werden.

Background: Atypical arousal regulation may explain slower mean reaction time (MRT) in autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder compared with typical development. The locus coeruleus–norepinephrine system (LC-NE) underlies arousal regulation and adapts its activity to the utility of a task. LC-NE tonic and phasic activity are indexed by baseline pupil size (BPS) and stimulus-evoked pupillary response (SEPR). Methods: The study assessed pupillometry in ASD (n = 31, 3 female/28 male), attention-deficit/hyperactivity disorder (n = 28, 3 female/25 male), and typically developing control subjects (n = 31, 16 female/15 male) during a visuospatial reaction-time task that manipulates arousal by conditions with low and high task utility. We estimated linear mixed models of BPS, SEPR, and MRT in a per-trial analysis to investigate arousal regulation of task performance. Results: Slower MRT occurred in the ASD group compared with the typically developing control group during low-utility conditions while controlling for dimensional ASD and attention-deficit/hyperactivity disorder symptoms. In low-utility conditions, BPS and SEPR were inversely related and both were associated with faster MRT. Increased ASD symptoms across groups were associated with higher BPS during low-utility conditions. Changes in BPS and SEPR between task-utility conditions were smaller in the ASD group. Conclusions: Slower visuospatial task performance in ASD is specific to low task utility. Arousal was associated with task performance and showed altered activity in ASD. Increased BPS during low-utility conditions suggested increased LC-NE tonic activity as an ASD symptom marker in children. Smaller changes in BPS and SEPR in ASD indicated attenuated LC-NE activity adaptation in response to high-utility conditions. Slower performance and atypical arousal regulation are probably associated with attenuated LC-NE activity adaptation. © 2021 Society of Biological Psychiatry

Background A shortage of general practitioners (GPs) is common to many European countries. To counteract this, it is essential to understand the factors that encourage or discourage medical students from choosing to become a GP Objective To evaluate medical students’ attitudes towards general practice and to identify factors that discourage them from considering a career as a GP. Methods In this multinational cross-sectional online survey, 29 284 students from nine German, four Austrian and two Slovenian universities were invited to answer a questionnaire consisting of 146 closed and 13 open-ended items. Results Of the 4486 students that responded (response rate: 15.3%), 3.6% wanted to become a GP, 48.1% were undecided and 34.6% did not want to be a GP. Significant predictors for interest in becoming a GP were higher age [odds ratio (OR) = 1.06; 95% confidence interval (CI) = 1.02–1.10], positive evaluation of the content of a GP’s work (OR = 4.44; 95% CI = 3.26–6.06), organizational aspects (OR = 1.42; 95% CI = 1.13–1.78), practical experience of general practice (OR = 1.66; 95% CI = 1.08–2.56) and the country of the survey [Slovenian versus German students (Reference): OR = 2.19; 95% CI = 1.10–4.38; Austrian versus German students (Reference): OR = 0.50; 95% CI = 0.32–0.79]. Conclusion Strategies to convince undecided students to opt for a career as a GP should include a positive representation of a GP’s work and early and repeated experience of working in a general practice during medical school.

The large majority of Hoya R.Br. species known from Papuasia were described in the first half of the 20th century and most of these are endemic. Along with Borneo and the Philippines the region is a c

Epistaxis is a common symptom in the medical practice. It is associated with various comorbidities and the use of medications, especially anticoagulants. Despite the high lifetime prevalence, there is limited data on prevalence and possible risk factors.The study examines epistaxis care in a large patient population (AOK Lower Saxony) over a ten-year period (2007-2016). Risk factors, age at diagnosis, concomitant medication and comorbidities were analysed and the prevalence in the study period calculated.162,167 patients visited their doctors between 2007-2016 (308,947 cases). Most patients were treated as outpatients (96.6%) and 54% of patients were men. Over the study period, the prevalence of epistaxis rose by 21% (increase from 8.6 to 9.3 per 1000 insured persons per year) with a comparatively stable prevalence for the inpatient setting (0.2 per 1000 insured persons per year). In 54,105 of all epistaxis cases (17.5%), the use of antithrombotic drugs was recorded (oral anticoagulants: 9.5%). During the study period, increased prescribing of oral anticoagulants (from 7.7% of cases in 2007 to 11.8% in 2016), especially of NOAC was documented (from 0.1% of cases in 2011 to 5.1% in 2016).In addition to arterial hypertension, the predominant male sex and the typical age distribution, we found that cases of epistaxis often received anticoagulation therapy. This study showed an increase of epistaxis along with rising prescriptions of NOAC. In contrast, no increase of severe epistaxis cases leading to hospitalization was found.HINTERGRUND: Die Epistaxis ist ein häufiges Symptom in der Arztpraxis und assoziiert mit verschiedenen Komorbiditäten und Medikamenten, insbesondere Antikoagulanzien. Trotz ihrer Alltäglichkeit gibt es nur wenige Daten zur Häufigkeit ihres Auftretens und möglichen Risikofaktoren.Die Studie untersuchte anhand einer großen Patientenpopulation (AOK Niedersachsen) über 10 Jahre (2007–2016) die Versorgung von Epistaxis in Niedersachsen. Alter bei Diagnose, Begleitmedikation und Komorbiditäten wurden analysiert und die Prävalenz dargestellt.162.167 Versicherte der AOK Niedersachen wurden zwischen 2007 und 2016 aufgrund einer Epistaxis in 308.947 Fällen ärztlich vorstellig. Die meisten Patienten wurden ausschließlich ambulant behandelt (96,6 %). Über den Studienzeitraum stieg die Prävalenz um 21 % (Anstieg von 8,7 auf 9,3 pro 1000 Versicherte/Jahr) bei stabiler Prävalenz für stationäre Vorstellungen (0,2 pro 1000 Versicherte/Jahr). Die höchsten Prävalenzen fanden sich bei Personen bis 20 und über 80 Jahre. In 17,5 % aller Epistaxisfälle wurden Antithrombotika erfasst (9,5 % orale Antikoagulanzien). Über den Studienzeitraum konnte eine erhöhte Verschreibung von Antikoagulanzien (7,7 % in 2007 auf 11,8 % in 2016, insbesondere NOAK) dokumentiert werden.Neben der arteriellen Hypertonie, dem männlichen Geschlecht sowie der typischen Altersverteilung bestand auch häufig eine Medikation mit Antikoagulanzien. Über den untersuchten Zeitraum zeigte sich eine Zunahme von Epistaxisfällen bei gleichzeitig ansteigender Verschreibungshäufigkeit von NOAK, nicht jedoch von schweren hospitalisationsbedürftigen Epistaxisfällen. Eine abschließende Beurteilung hinsichtlich eines möglichen kausalen Zusammenhangs muss in weiteren Studien untersucht werden.

Objectives: On the basis of current treatment guidelines, we developed and validated a medication-based chronic disease score (medCDS) and tested its association with all-cause mortality of older outpatients.Study Design and Setting: Considering the most prevalent chronic diseases in the elderly German population, we compiled a list of evidence-based medicines used to treat these disorders. Based on this list, a score (medCDS) was developed to predict mortality using data of a large longitudinal cohort of older outpatients (training sample; MultiCare Cohort Study). By assessing receiver-operating characteristics (ROC) curves, the performance of medCDS was then confirmed in independent cohorts (ESTHER, KORA-Age) of community-dwelling older patients and compared with already existing medication-based scores and a score using selected anatomical-therapeutic-chemical (ATC) codes.Results: The final medCDS score had an ROC area under the curve (AUC) of 0.73 (95% CI 0.70-0.76). In the validation cohorts, its ROC AUCs were 0.79 (0.76-0.82, KORA-Age) and 0.74 (0.71-0.78, ESTHER), which were superior to already existing medication-based scores (RxRisk, CDS) and scores based on pharmacological ATC code subgroups (ATC3) or age and sex alone (Age&Sex).Conclusions: A new medCDS, which is based on actual treatment standards, predicts mortality of older outpatients significantly better than already existing scores. (C) 2018 Elsevier Inc. All rights reserved.

Background: Prostate cancer (PCa) is the most frequent cancer and the third leading cause of cancer death among German men. One option for PCa early detection is prostate-specific antigen (PSA) testing, which is still under debate regarding its risk benefits. Besides recommendations on the early PCa detection, daily practice on PSA testing varies in, for example, information communication and usage of the test. This pilot study assessed potential differences between general practitioners (GPs) and urologists in handling PSA testing and guidelines on early detection of PCa. Methods: 172 GPs belonging to the teaching network of the University of Oldenburg in Lower Saxony and Bremen and 128 practicing urologists were included in the online survey focusing on PSA testing. The questionnaire covered 43 questions on topics as the usage of the test, information communication, handling of test results and handling of/knowledge about national and international guidelines on PCa. Wether PSA testing is used in accordance with guidelines was also explored in four standardized case scenarios. Statistical analysis was done at a descriptive level. Results: In total, 65 doctors participated in the survey (response proportion: 21.7%, n=65; 27.9%, n=48 [GPs]; 13.2%, n=17 [urologists]). Results of 41 GPs and 14 urologists were analyzed. The PSA test was judged as useful by all urologists, while almost half of the GPs valued the test as ambivalent or not useful. Urologists showed a more proactive approach of informing men on PSA testing. Regarding guidelines and recommendations on PSA testing, GPs were less familiar with them compared to the urologists. Doctors of both specialties did not always treat men in consistence with the guidelines. This was partially in contradiction to their self-appraisal. Conclusion: This pilot study is highlighting differences in PSA testing practices between GPs and urologists in Germany. Urologists showed a more proactive approach. For further verification, we plan a more comprehensive study covering several German states.

Importance Controversies about the choice of antibiotic agent and treatment modality exist in the management of erythema migrans in early cutaneous Lyme borreliosis (LB). Objective To conduct a network meta-analysis (NMA) of all randomized clinical trials on various antibiotic agents and treatment modalities in early cutaneous LB. Data Sources Electronic searches in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were conducted from inception until July 2017. The reference lists of the included studies were hand searched, authors were contacted, and ongoing trials were searched at ClinicalTrials.gov. Study Selection One reviewer screened the titles and abstracts of the 9975 reports identified by the electronic searches. Full-text copies of 161 potentially relevant articles were obtained, and 2 reviewers independently assessed those articles for inclusion. Adults with a physician-confirmed early localized skin infection who were treated with antibiotics of any dose or duration were included. Data Extraction and Synthesis Two reviewers independently extracted data on study, patient, and intervention characteristics. Network meta-analyses on treatment effects and adverse outcomes were calculated with a frequentist approach using the R package netmeta. The Grading of Recommendations Assessment, Development and Evaluation guidance for NMA was used to assess the certainty of evidence. Main Outcomes and Measures Treatment effects for response to treatment (resolution of symptoms) and treatment-related adverse events. Results Overall, 19 studies (2532 patients) were included. The mean patient age ranged between 37 and 56 years, and the percentage of female patients ranged from 36% to 60%. The antibiotics investigated were doxycycline, cefuroxime axetil, ceftriaxone, amoxicillin, azithromycin, penicillin V, and minocycline. Pooled effect sizes from NMAs did not suggest any significant differences in treatment response by antibiotic agent (eg, amoxicillin vs doxycycline odds ratio, 1.26; 95% CI, 0.41-3.87), dose, or duration (eg, doxycycline, 200 mg/d for 3 weeks, vs doxycycline, 200 mg/d for 2 weeks, odds ratio, 1.28; 95% CI, 0.49-3.34). Treatment failures were rare at both 2 months (4%; 95% CI, 2%-5%) and 12 months (2%, 95% CI, 1%-3%) after treatment initiation. There were also no differences in the effect sizes among antibiotic agents and treatment modalities for treatment-related adverse outcomes, which were generally mild to moderate. Certainty of evidence was categorized as low and very low mostly because of imprecision, indirectness, and study limitations (high risk of bias) of the included studies. Conclusions and Relevance This NMA suggests that neither the antibiotic agent nor treatment modality contributed to comparative effectiveness or drug-related adverse outcomes. This finding is relevant for physicians treating patients with LB and for patient decision making.

Aims This population-based study assesses the healthcare utilization of people with Type 2 diabetes by analysing routine data from Allgemeine Orts-Krankenkasse (AOK), the largest statutory health insurance provider in Germany. Methods Anonymized billing data from all AOK-insured persons with at least one day of insurance during the evaluation year 2010 were analysed. Treatment and cost data from all areas of inpatient and outpatient care were available, as was information regarding patient age and sex. International Classification of Diseases (ICD–10) diagnosis and Anatomical Therapeutic Chemical (ATC) classification were used to identify 2.7 million insured persons with diabetes. Results The age- and sex-standardized prevalence of Type 2 diabetes was 9.8%. Of those patients identified, 33.9% had at least one diabetes-related complication and 83.0% had a diagnosis of hypertension. Almost two-thirds (63.1%) received antihyperglycaemic medication. Metformin and sulfonylurea were prescribed most often; medications without proof of benefit in endpoint studies were prescribed much less frequently. People without diabetes were admitted to hospital only half as often as those with Type 2 diabetes. The projected total expenditure in Germany for all people with Type 2 diabetes amounted to approximately €33.3 billion in 2010. Conclusions This study shows an increase in both the prevalence of diabetes and treatment costs. The majority of people with Type 2 diabetes were aged 70 years or older. One third of this group has diabetes-related complications. Antihyperglycaemic medications without proof of benefit in endpoint studies were prescribed much less frequently than drugs with proof of benefit.

Summary What is known and objective Metamizole (dipyrone) is an analgesic that has been the focus of considerable controversy regarding its safety. Because of potentially life-threatening blood disorders such as agranulocytosis, it has been withdrawn in many countries but not in Germany, where prescribing even increased over recent years. We aimed to evaluate prescribing of metamizole in Germany with respect to age, sex and regional variations. Methods Using data of a statutory health insurance, we analysed a cohort of 1·7 million persons who were insured at least 1 day in each quarter of 2009. Outcome of interest was the outpatient prescription prevalence, for example the proportion of persons receiving at least one prescription of metamizole. Results and discussion A total of 6·8% received metamizole with a higher prescribing prevalence in females (7·8% vs. 6·0%). The prevalence increased with age up to 26·7% in persons ≥85 years (men: 21·1%; and women: 30·4%). We found large regional variations with higher prevalences in the northern part of Germany. Most of the prescriptions were issued by general practitioners (78·9%). 58·3% were liquid oral formulations with considerable regional variations ranging between 32·3% in Mecklenburg-West Pomerania and 67·3% in North Rhine-Westphalia. Overall, liquid oral forms are much more often prescribed in the western than in the eastern part of Germany. What is new and conclusion Metamizole – a drug with a relatively narrow indication – is often prescribed in Germany with relevant differences by age, sex and region. Qualitative studies should clarify reasons for this. Further quantitative research should investigate small-area variations, indications and treatment durations.

Ziel des vorliegenden Beitrages ist es, mogliche „Integrationsfenster“ auf Ebene der zwei Wissensfelder „Gender und Medizin“ sowie „Gender und Entrepreneurship/Innovation“ zu identifizieren, die das Ent- und Bestehen von Innovationen im Gesundheitswesen begunstigen. Hierauf aufbauend stellt der Beitrag Implikationen vor, die Ansatzpunkte bieten fur die (1) Forderung einer gendersensiblen Grundungskultur im Gesundheitswesen sowie (2) Integration von Gendered-Entrepreneurship- & Innovation-Elementen in der Ausbildung von Gesundheitsberufen. Die nachfolgenden Ausfuhrungen verorten sich damit in der anwendungsorientierten, medizinischen Geschlechterforschung und verbinden die fachlichen Perspektiven der Versorgungsforschung mit sozialwissenschaftlichen Zugangen der Forschung zum Thema Gendered Entrepreneurship & Innovation. Ein besonderes Augenmerk wird hierbei auf Aspekte der offentlichen Gesundheit (Public Health) sowie der individuellen medizinischen Versorgung in der hausarztlichen Praxis gelegt.

Background: Influenza vaccination coverage in Germany does not meet the recommendation of the World Health Organization. Nursing home residents are an especially vulnerable subgroup. It is not known whether vaccination coverage rates differ between nursing home residents and non-institutionalised persons[for full text, please go to the a.m. URL], 51. Kongress für Allgemeinmedizin und Familienmedizin

Wir untersuchten bei alteren, multimorbiden Patienten den Gebrauch von verschreibungspflichtigen und nicht verschreibungspflichtigen Schmerzmitteln (OTC, „over the counter“) und damit verbundene Risiken. Insbesondere uber deren kombinierten Einsatz ist in Deutschland wenig bekannt. Der Schmerzmittelgebrauch wurde in den Baselinedaten (2008/2009) der MultiCare-Kohorte mit primararztlich versorgten alteren multimorbiden Patienten untersucht (Trial registration: ISRCTN89818205). Berucksichtigt wurden Opioide, andere Analgetika und Antipyretika sowie nichtsteroidale Antirheumatika. Gebrauch von OTC-Praparaten, Dosierungen, Doppelmedikation und Interaktionen wurden fur Acetylsalicylsaure, Diclofenac, (Dex)Ibuprofen, Naproxen und Paracetamol untersucht. Von 3189 multimorbiden 65- bis 85-jahrigen Patienten gaben 1170 Patienten an, innerhalb der letzten 3 Monate mindestens ein Schmerzmittel eingenommen zu haben (36,7 %). Mindestens ein OTC-Schmerzmittel nahmen 289 Patienten (24,7 % von 1170) ein. Doppelmedikation mit wirkstoffgleichen Praparaten erfolgte in 86 Fallen, von diesen regelmasig in 15 Fallen. In 2 Fallen wurde durch Doppelmedikation die maximale Tagesdosis an Diclofenac uberschritten. In 235 Fallen nahmen Patienten parallel einen potenziell klinisch relevanten interagierenden Wirkstoff ein. In 43 Fallen (18,3 %) Fallen war ein OTC-Schmerzmittel, meist Ibuprofen, beteiligt. Uber ein Drittel der alteren Patienten nahm regelmasig oder bei Bedarf Schmerzmittel ein. Trotz des relativ hohen Gebrauchs von OTC-Schmerzmitteln ist der Anteil an Doppelmedikationen, Uberdosierungen und Interaktionen durch OTC-Praparate gering.

Ochotonophila flava Dickoré & Freitag sp. nov. (Caryophyllaceae – Silenoideae) is described from the mountains of Bamiyan Province, central Afghanistan. It differs from the two previously known species endemic to Afghanistan, Ochotonophila allochrusoides Gilli and O. eglandulosa Hedge & Wendelbo, by its cream to yellow petals and elliptic leaves. A key to the identification of Ochotonophila species is provided; distribution and ecology are outlined.

Epidemiological studies assessing general and abdominal obesity measures or their combination for mortality prediction have shown inconsistent results. We aimed to systematically review the associations of body mass index (BMI), waist-to-hip ratio (WHR), waist circumference (WC) and waist-to-height ratio (WHtR) with all-cause mortality in prospective cohort studies. In this systematic review, which includes a meta-regression analysis, we analysed the associations with all-cause mortality of BMI, WHR, WC and WHtR in prospective cohort studies available in Medline, Embase, the Cochrane Database of Systematic Reviews and Esbiobase from inception through 7 May 2010. A total of 18 studies met the inclusion criteria, comprising 689, 465 participants and 48, 421 deaths during 5-24 years of follow-up. The studies were heterogeneous, mainly due to differences in categorization of anthropometric parameters (AP) and different approaches to statistical analysis. Both general and abdominal obesity measures were significantly associated with mortality. In analyses using categorical variables, BMI and WC showed predominantly U- or J-shaped associations with mortality, whereas WHR and WHtR demonstrated positive relationships with mortality. All measures showed similar risk patterns for upper quantiles in comparison to reference quantiles. The parameters of general and abdominal obesity each remained significantly associated with mortality when adjusted for the other. This evidence suggests that abdominal obesity measures such as WC or WHR, show information independent to measures of general obesity and should be used in clinical practice, in addition to BMI, to assess obesity-related mortality in adults.

Background: Antibiotic resistance is a worldwide problem and inappropriate prescriptions are a cause. Especially among children, prescriptions tend to be high. It is unclear how they differ in bordering regions. This study therefore examined the antibiotic prescription prevalence among children in primary care between northern Netherlands and north-west of Germany.Methods: Two datasets were used: The Dutch (IADB) comprises representative data of pharmacists in North Netherland and the German (BARMER GEK) includes nationwide health insurance data. Both were filtered using postal codes to define two comparable bordering regions with patients under 18 years for 2010.Results: The proportion of primary care patients receiving at least one antibiotic was lower in northern Netherlands (29.8 %; 95 % confidence interval [95 % CI]: 29.3-30.3), compared to north-west Germany (38.9 %; 95 % CI: 38.2-39.6). Within the respective countries, there were variations ranging from 27.0 to 44.1 % between different areas. Most profound was the difference in second-generation cephalosporins: for German children 25 % of the total prescriptions, while for Dutch children it was less than 0.1 %.Conclusions: This study is the first to compare outpatient antibiotic prescriptions among children in primary care practices in bordering regions of two countries. Large differences were seen within and between the countries, with overall higher prescription prevalence in Germany. Considering increasing cross-border healthcare, these comparisons are highly valuable and help act upon antibiotic resistance in the first line of care in an international approach.

Background: To test whether quality of life depends on the psyche of patients after successful bypass surgery for peripheral arterial disease (PAD). Patients and methods: A total of 74 consecutive patients aged 36–69 years (57.7 ± 8.8 years) with symptomatic PAD in the stages Fontaine IIb–IV were enrolled in a prospective study after successful bypass surgery. Because of bypass failure and one death during the study period, 11 of these patients were excluded from evaluation. Prior to surgery, Doppler sonography and digital subtraction angiography were carried out in all patients. Before and after revascularization, the ankle / brachial index (ABI) was determined in all study objects and the pain free walking distance (PFWD) in those with PAD stage Fontaine IIb. Health-related quality of life was measured by using the "Medical Outcomes Study Group Short Form 36" (SF-36), and personality was determined by employing the Psycho-Diagnostic-Test (PDT). Results: After surgery, there was an increase in ABI from 0.32 ± 0.13 to 0.79 ± 0.19 (p < .01), in PFWD from 42.6 m ± 38.6 m to 419.7 m ± 152.3 m (p < .01), and in the SF-36 scales "Physical functioning", "Bodily pain", "General health perceptions", and "Role-functioning physical" (p < .05). ABI correlated positively with "Bodily pain" (p < .01), "General health perceptions" (p < .01) and "Mental health" (p < .05). Among SF-36 and PDT-scales, "Role-functioning physical" correlated negatively with "Moodiness" / "Neuroticism" (p < .05), and "Social functioning" correlated positively with "General activity" (p < .01). Conclusions: Whether objective clinical improvement increases quality of life mainly depends on the psyche of patients: A high level of general activity favors an improved quality of life and neurotic characteristics are more likely to be a hindrance.

Introduction Benign epilepsy with centrotemporal spikes (BECTS) is a common epilepsy syndrome in childhood. Besides the occurrence of seizures, mild cognitive impairments and behavioral problems affecting language skills, spatial perception, memory, executive function, and academic achievement might be present. There is no international consensus about the decision whether or not to treat affected children. The influence of treatment on cognitive functions is debated. Methods Patients diagnosed with BECTS were assessed in short term auditory memory, long-term verbal memory, intelligence and behavior using the “number recall” test from the Kaufman assessment battery for children, the “verbal learning memory test”, the “culture free intelligence test” and the “child behavior checklist” prior to a randomized controlled antiepileptic therapy and after a treatment period of 6 months with either sulthiame or levetiracetam. Results 43 of 44 randomized patients were analyzed. One patient had to be excluded due to protocol violation. Patients who completed the study showed a non-significant improvement in parent-reported behavioral problems under therapy. Cognitive skills were not affected. Conclusion The present data suggest that antiepileptic drug treatment of children with BECTS with either sulthiame or levetiracetam does not affect cognitive performance. Behavior improved in a subset of patients though not reaching statistical significance.

Background Erythema migrans represents an early cutaneous and most common manifestation of Lyme borreliosis. Recommendations regarding pharmacological agents, dose and duration of treatment are subject of intense debate. This review aims to explore differences in efficacy and safety between pharmacological treatments and control treatment. Methods To identify relevant studies, we will conduct a systematic literature search. We will include randomised controlled trials (RCTs) and non-RCTs. Eligible comparative studies need to (1) consider patients with a diagnosis of erythema migrans resulting from Lyme borreliosis and (2) compare different pharmacological agents against each other, against any other non-pharmacological treatment, placebo or no treatment. Two review authors will independently assess included studies for risk of bias according to the methods of the Cochrane Handbook for Systematic Reviews of Interventions and related to specific study designs. We will address patient-relevant outcomes including clinical remission of cutaneous symptoms, any treatment-related adverse events, quality of life and progressive symptoms such as neuroborreliosis or Lyme carditis and flu-like symptoms. Provided that the identified trials are comparable in terms of clinical issues, combined estimates will be provided. Estimations of treatment effects will be calculated based on a random effects model. Heterogeneity will be evaluated based on I2 and chi-square test. In case of significant heterogeneity, a pooled estimate will not be provided, but heterogeneity will be investigated on the basis of methodological and clinical study aspects. We plan subgroup analysis to reveal potential differences in the effect estimates between patient populations and treatment specifications. We will consider risk of bias using sensitivity analyses to decide whether to rely on the pooled estimates. The quality of a body of evidence for individual outcomes will be assessed using the GRADE approach. Discussion Benefits and harms of pharmacological treatment in erythema migrans have not yet been adequately assessed. This systematic review will evaluate and summarise available evidence addressing benefits and harms of different pharmacological treatments. In addition, this summary of clinical evidence will inform decision-making between clinicians and patients and will play an important part in patient care. Systematic review registration PROSPERO: CRD42016037932 Electronic supplementary material The online version of this article (doi:10.1186/s13643-016-0251-3) contains supplementary material, which is available to authorized users.

PURPOSE To test the "Questionnaire for Life Quality in Patients with Peripheral Arterial Occlusive Disease at the Stage of Critical Ischemia" (FLeQKI) in a prospective study with respect to responsiveness and practicability. PATIENTS AND METHODS The responsiveness of the FLeQKI for therapy-induced changes of health related quality of life was prospectively determined in 65 consecutive patients with peripheral occlusive arterial disease at the stage of critical ischemia prior to percutaneous transluminal angioplasty (PTA) or bypass operation, and 1 month and 6 months after. 40 healthy individuals who were matched for age and questioned with the FLeQKI twice within 6 months served as the control. Additionally, all patients and healthy volunteers were questioned with the "Medical Outcomes Study Group Short Form" (SF-36). In all patients, the ankle/brachial index (ABI) was measured along with each of the three interviews. To validate practicability, we measured the time needed to fill out the questionnaires and asked the patients to indicate on a visual analog scale (VAS) graduated from 0 - 10 how strenuous they found the questionnaires to be. For statistical analysis, two-sided paired t-tests were used. RESULTS The treatment group consisted of 35 men and 30 women with an age of 75.1+/-7.0 years, and the control group was comprised of 21 men and 19 women with an age of 73.4+/-7.8 years. In the control group, none of the FLeQKI scales showed significant changes over time (p>0.05). In the pAVK group, all scales improved between the interviews before and 6 months after therapy. Changes were either significant (comorbidity, p 0.05) as non-strenuous. CONCLUSION Regarding responsiveness and practicability, the FLeQKI is well suited for determining the specific impairments of life quality in patients with peripheral arterial occlusive disease in the stage of critical ischemia. Compared with the SF-36, the FLeQKI reached similar or better psychometric values.

PURPOSE To develop a disease-specific measuring instrument for quality of life in German-speaking patients with peripheral arterial occlusive disease in the stage of critical ischemia and to test it in a prospective study for validity and reliability. MATERIALS AND METHODS We developed a questionnaire compiling items representing subjective disease relevant health states. With 35 of these items, we designed the scales comorbidity (KO), physical pain (SZ), physical functioning (KF), physical state (KS), social functioning (SB), mental health (PB), and therapy-induced limitations (TE). Each item was to be valued as never, seldom, often or always. The scales were standardized with a control group of 40 individuals without peripheral arterial occlusive disease who were interviewed twice in an interval of 6 months using both the FLeQKI and the Medical Outcomes Study Group Short Form 36 (SF-36). Convergent and discriminative validity was determined in 65 consecutive in-patients with peripheral occlusive arterial disease in the stage of critical ischemia who were interviewed with FLeQKI and SF-36 prior to percutaneous transluminal angioplasty (PTA) or bypass operation and 1 month and 6 months after. The internal consistency and test-retest reliability of the FLeQKI were determined in the control group. For statistical analysis, Cronbach's alpha Test and Pearsons Product Moment Correlation were used. RESULTS The control group consisted of 21 men and 19 women with an age of 73.4+/-7.8, and the treatment group was comprised of 35 men and 30 women with an age of 75.1+/-7.0. In the treatment group, convergent validity reached high values in the scales SB, KF, PB, and SZ (r=0.41-0.70). With their discriminative validity (r=-0.04-0.30), TE and KS were independent, specific dimensions of life quality. The control group showed good values for internal consistency (Cronbach's alpha=0.54-0.93) and for test-retest reliability (r=0.44-0.96). CONCLUSION The FLeQKI is well suited for determining the specific impairments of life quality in patients with peripheral arterial occlusive disease at the stage of critical ischemia. Its psychometric scores for validity and reliability corresponded to those of the SF-36.

Pain is a highly prevalent symptom in nursing home residents. The analgesic pharmacotherapy of older adults is associated with challenges; however, studies from Germany examining the prescription pattern of analgesics in nursing home residents are rare.This study was carried out to examine the prescription of analgesics in nursing home residents with and without the diagnosis of cancer.Using health insurance claims data persons aged ≥ 65 years who were newly admitted to a nursing home between 2004 and 2009 and who survived at least the first 90 days after admission were included in the study. Cancer was identified by outpatient diagnoses of malignant neoplasms (ICD-10: C00-C97). Prescription drugs within the first 90 days after admission to a nursing home were analyzed which means that aspirin and acetaminophen were not taken into account.A total of 5549 nursing home residents were included, who were on average 81.5 years old (56.8 % females). More than half (53.5 %) were assigned to care level I and 781 (14.1 %) were diagnosed with cancer. The study cohort received on average 7.8 different medications (with vs. without cancer: 8.6 vs. 7.6, respectively) and 43.8 % had prescriptions for analgesics (with vs. without cancer: 52.5 vs. 42.3 %, respectively). A total of 37.1 % were taking WHO step 1 analgesics (step 2: 11.4 % and step 3: 9.2 %). The proportion of persons receiving metamizole (dipyrone) was 28.3 % (with vs. without cancer: 35.6 vs. 27.1 %, respectively). Regarding all prescriptions, metamizole was by far the most frequently prescribed medication in nursing homes followed by melperone and omeprazole.Approximately one third of nursing home residents received metamizole and most were long-term prescriptions. Considering that metamizole is associated with potentially life-threatening adverse effects, caution is indicated particularly when prescribed over long periods.

PURPOSE To determine the current incidence of major amputations, bypass procedures and percutaneous transluminal angioplasties (PTA) in a study population of patients with peripheral arterial occlusive disease in a German referral center. MATERIALS AND METHODS In a retrospective study, we recruited patients with peripheral arterial occlusive disease who underwent an amputation, bypass procedure, or PTA in the region of the pelvis or lower limbs between 1996 and 2003 at the Augsburg Medical Center. Patients were identified via the hospital database. This was performed with the help of the International Classification of Diseases (ICD 9 and 10), the operation code (OPS), and appropriate invoices. The incidence of PTAs was further estimated with 200 charts. RESULTS Of 5379 patients, 627 underwent amputation, 1832 a bypass procedure, and 2920 a PTA. The incidence of PTAs increased during the study period from 51.3/100 000/year to 64.4/100 000/year (p < 0.01), while the number of amputations and bypass procedures remained stable. The incidence of PTAs was exceeded by that of bypass procedures only in patients older than 85 years. The age of the amputees decreased during the study period from 72.2 to 70.5 years (p < 0.01). The age of patients who underwent a bypass procedure increased from 67.2 to 69.4 years, and the age of patients who underwent PTA increased from 66.3 to 69.8 years (p < 0.01). Bypass procedures and PTAs were performed in men 6.3 years earlier than in women (p < 0.01). CONCLUSION The result is a population-corrected need of 8.4/100 000/year major amputations, 23/100 000/year bypass procedures and 64.4/100 000/year PTAs for patients with peripheral arterial occlusive disease within the referral area of our hospital. The performance of major amputations and bypass procedures stagnates, while the incidence of PTAs is increasing.

Salsola cyrenaica subsp. antalyensis (Chenopodiaceae) from the S Anatolian coast near Finike is illustrated and described as a new subspecies. Its anatomy, relationships, ecology and phytogeography are discussed. The new subspecies differs from subsp. cyrenaica by the reduced number of flowers per leaf axil, very dense axillary hairs, the smaller size of most floral organs, mostly 3 instead of 2 stigmas and 5 not 3 wings on the fruit. The new taxon grows in a narrow coastal strip of c.2km only, in open dwarf-shrub communities on limestone rocks from sea level to c.40m. It is the first representative of the S. longifolia group, sect. Coccosalsola, from Turkey and from the northern shores of the Mediterranean.

Increased brain natriuretic peptide (BNP) expression in the ventricles antedates elevated blood pressure (BP) in experimental studies. We hypothesized that higher plasma BNP levels in nonhypertensive individuals may be associated with a greater likelihood of future BP increase and/or hypertension. We evaluated the relations of plasma BNP to longitudinal BP tracking and incidence of hypertension in 1801 nonhypertensive Framingham Heart Study participants (mean age, 56 years; 57% women) by using gender-specific multivariable logistic regression. Progression of BP stage was defined as an increment of one or more BP categories, as classified by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). Hypertension was defined as a systolic BP ≥140 or diastolic BP ≥90 mm Hg or use of antihypertensive medications. On follow-up 4 years from baseline, progression of BP category was observed in 36.2% of men and 33.1% of women; hypertension developed in 16.4% of men and 15.5% of women. In multivariable models adjusting for known risk factors, elevated plasma BNP level was associated with increased risk of BP progression in men (odds ratio of 1.15 for trend across categories, P =0.046) but not in women ( P =0.82). There were no significant trends of increasing incidence of hypertension across BNP categories in men or women. In our community-based sample, higher plasma BNP levels were associated with increased risk of BP progression in men but not women. Additional investigations are warranted to confirm these findings and elucidate the basis for these gender-related differences.

Zusammenfassung: Die Studie untersuchte anhand von theoretischen, statistischen und empirischen Kriterien die Eignung verschiedener bisheriger Kurzformen für den HAWIK-III bei pädiatrischen Patienten mit Epilepsie. Es wurde geprüft, welche Untertests in dieser Klientel den Gesamtwert am besten vorhersagen und welche Untertests bei fokalen Epilepsien das Leistungsprofil am besten kennzeichnen. Ausgewählt wurde schließlich eine Kurzform mit den Untertests “Wortschatz”, “Mosaiktest”, “Bilderordnen”, “Zahlen-Symbol-Test” und “Allgemeines Wissen”, wie sie von Basler 1974 für den HAWIK-R vorgeschlagen wurde. Für diese Kurzform wird über multiple Regression eine Schätzformel aufgestellt und an einer zweiten Stichprobe kreuzvalidiert. Die Ergebnisse zeigen, dass in den meisten Fällen eine ausreichend exakte Schätzung des Gesamt-IQ durch die Kurzform möglich ist. Wichtige Fehlerquellen (Extremwerte, heterogene Testprofile) werden diskutiert.

Introduction Multimorbidity is a major concern in primary care. Nevertheless, evidence of prevalence and patterns of multimorbidity, and their determinants, are scarce. The aim of this study is to systematically review studies of the prevalence, patterns and determinants of multimorbidity in primary care. Methods Systematic review of literature published between 1961 and 2013 and indexed in Ovid (CINAHL, PsychINFO, Medline and Embase) and Web of Knowledge. Studies were selected according to eligibility criteria of addressing prevalence, determinants, and patterns of multimorbidity and using a pretested proforma in primary care. The quality and risk of bias were assessed using STROBE criteria. Two researchers assessed the eligibility of studies for inclusion (Kappa = 0.86). Results We identified 39 eligible publications describing studies that included a total of 70,057,611 patients in 12 countries. The number of health conditions analysed per study ranged from 5 to 335, with multimorbidity prevalence ranging from 12.9% to 95.1%. All studies observed a significant positive association between multimorbidity and age (odds ratio [OR], 1.26 to 227.46), and lower socioeconomic status (OR, 1.20 to 1.91). Positive associations with female gender and mental disorders were also observed. The most frequent patterns of multimorbidity included osteoarthritis together with cardiovascular and/or metabolic conditions. Conclusions Well-established determinants of multimorbidity include age, lower socioeconomic status and gender. The most prevalent conditions shape the patterns of multimorbidity. However, the limitations of the current evidence base means that further and better designed studies are needed to inform policy, research and clinical practice, with the goal of improving health-related quality of life for patients with multimorbidity. Standardization of the definition and assessment of multimorbidity is essential in order to better understand this phenomenon, and is a necessary immediate step.

Background Neuroborreliosis is a tick-borne infectious disease of the nervous system caused by Borrelia burgdorferi. Common clinical manifestations of neuroborreliosis are cranial nerve dysfunctions, polyradiculoneuritis, and meningitis. Diagnosis is usually based on clinical presentation, serologic testing, and analysis of cerebrospinal fluid. Many aspects of pharmacological treatment, such as choice of drug, dosage, and duration are subject of intense debate, leading to uncertainties in patients and healthcare providers alike. To approach the questions regarding pharmacological treatment of neuroborreliosis, we will perform a systematic review. Methods We will perform a comprehensive systematic literature search for potentially eligible studies that report outcomes after pharmacological interventions. To adequately consider the wealth of research that has been conducted so far, this review will evaluate randomized controlled trials (RCTs) and non-randomized studies on treatment of neuroborreliosis. We will assess potential risk of bias for each RCT meeting our selection criteria using the Cochrane risk of bias tool for RCTs. For non-randomized studies, we will use the Newcastle-Ottawa Scale and the recently piloted Cochrane risk of bias tool for non-randomized studies. Our primary outcome of interest will be neurological symptoms and the secondary outcomes will be disability, patient-reported outcomes (quality of life, and, if reported separately from other neurological symptoms, pain, fatigue, depression, cognition, and sleep), adverse events, and cerebrospinal fluid pleocytosis. Pooling of data and meta-analysis will only be deemed justified between studies with similar design (e.g., RCTs are only combined with other RCTs), characteristics (e.g., similar populations), and of acceptable heterogeneity (I2