S3 Guideline Research Articles

Angsterkrankungen in der Rehabilitation

Anxiety disorders are among the most common and socio-medically relevant mental illnesses. Correct diagnosis and initiation of appropriate therapy are of the utmost importance for patients' prognosis and for ensuring their social and occupational participation. This article therefore aims to provide an overview of new developments in the field of anxiety disorders relevant to rehabilitation.Within the framework of the changes in ICD-11, anxiety disorders now receive an independent chapter with a focus appropriate to their frequency and relevance. Further innovations concern the revised S3 guideline (2020) with the increasing consideration of digital therapy options, such as virtual reality exposure therapy (VER) as well as Internet-supported therapy methods as part of the therapy recommendations. Systemic therapy is also considered for the first time. However, the evidence for both procedures is significantly lower than for behavioral therapy, psychodynamic therapy, or pharmacotherapy. Online interventions are therefore not recommended as the sole therapy.Important for the practice in rehabilitation is the knowledge of the core symptoms of each of the above mentioned diagnoses as well as the diagnostic possibilities taking into account especially the correlations and interactions with physical diseases.Both psychotherapy and psychopharmacotherapy are available for treatment. In the field of psychotherapy, cognitive behavioral therapy (CBT) is the therapy of first choice due to the broadest base of evidence. In consideration of comorbid somatic diseases, attention must be paid to possible contraindications for antidepressants. Psychosomatic rehabilitation is an important resource in the overall treatment spectrum, especially if chronification or a threat to participation is foreseeable, in order to give the affected person confidence and motivation for further successful treatment of the anxiety disorder in an intensified treatment setting, in addition to teaching anxiety management strategies and socio-medical clarification. An important task of somatic rehabilitation is to recognize comorbid anxiety disorders and to provide the affected persons with an appropriate explanatory model of their complaints and to be able to initiate targeted treatment.

Larynx preservation up to T4 laryngeal cancer?

Kann die primäre Radiochemotherapie (pRCT) möglicherweise als alternative Standardtherapie zur totalen Laryngektomie (TL) angesehen werden? Gemäß der neuen S3-Leitlinie nehme der Patient zwar eine höhere Rückfallrate in Kauf, habe aber die Salvagechirurgie als kurative Option und insgesamt keinen Überlebensnachteil. In mehreren großen Datenbankanalysen und Fallserien findet sich für das T4-Larynxkarzinom ein signifikanter Überlebensnachteil der pRCT gegenüber der primären TL von über 30 %. Die Erfolgsrate der Salvagelaryngektomie beim T4-Karzinom liegt laut Literatur nur bei 25–50 %. Larynxorganerhaltstudien, die zur Empfehlung der pRCT als alternativer Standardtherapie führen könnten, sollten 1.) T4a-Karzinompatienten innerhalb ihrer T‑Kategorie auswerten, 2.) getrennt nach Larynx- und Hypopharynxkarzinomen, 3.) in aussagekräftiger Kollektivgröße, 4.) mit einem Nachbeobachtungszeitraum von mindestens 5 Jahren, 5.) mit onkologischen und 6.) funktionellen Outcome (Dauer von Tracheostoma u./o. PEG, Notwendigkeit und Erfolg einer Salvagelaryngektomie). 7.) Angabe des Kriteriums, das zur T4-Kategorie führte (Knorpeldurchbruch oder Art der extralaryngealen Ausbreitung), 8.) prätherapeutische Larynxfunktionalität (Tracheostoma, PEG). Eine Erfassung der genannten klinischen Daten aller T4-pRCT-Patienten in einer prospektiven beobachtenden Kohortenstudie im deutschsprachigen Raum wird vorgeschlagen. Bei Ablehnung der TL beim T4a-Karzinom sollte in ausführlichen einfühlsamen, aber instruktiven Gesprächen unterschieden werden zwischen einer primären spontanen Abneigung und der differenziert abgewogenen, definitiven Ablehnung. Nicht nur der onkologische, sondern auch der funktionell zu erwartende Outcome sollte in den Entscheidungsprozess einbezogen werden.

Update on Percutaneous Local Ablative Procedures for the Treatment of Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the fifth most common tumor worldwide. Because many hepatocellular carcinomas are already unresectable at the time of initial diagnosis, percutaneous tumor ablation has become established in recent decades as a curative therapeutic approach for very early (BCLC 0) and early (BCLC A) HCC. The aim of this paper is to provide a concise overview of the percutaneous local ablative procedures currently in use, based on their technical characteristics as well as clinical relevance, taking into account the current body of studies. The literature search included all original papers, reviews, and meta-analyses available via MEDLINE and Pubmed on the respective percutaneous ablation procedures; the primary focus was on randomized controlled trials and publications from the last 10 years. Radiofrequency ablation (RFA) and microwave ablation (MWA) are well-established procedures that are considered equal to surgical resection in the treatment of stage BCLC 0 and A HCC with a diameter up to 3 cm due to their strong evidence in international and national guidelines. For tumors with a diameter between 3 and 5 cm, the current S3 guidelines recommend a combination of transarterial chemoembolization (TACE) and thermal ablation using RFA or MWA as combination therapy is superior to thermal ablation alone in tumors of this size and shows comparable results to surgical resection in terms of overall survival. Alternative, less frequently employed thermal procedures include cryotherapy (CT) and laser ablation (LA). Non-thermal procedures include irreversible electroporation (IRE), interstitial brachytherapy (IBT), and most recently, electrochemotherapy (ECT). Due to insufficient evidence, these have only been used in individual cases and within the framework of studies. However, the nonthermal methods are a reasonable alternative for ablation of tumors adjacent to large blood vessels and bile ducts because they cause significantly less damage to these structures than thermal ablation methods. With advances in the technology of the respective procedures, increasingly good evidence, and advancements in supportive techniques such as navigation devices and fusion imaging, percutaneous ablation procedures may expand their indications for the treatment of larger and more advanced tumors in the coming years. · RFA and MWA are considered equal to surgical resection asa first-line therapy for the curative treatment of stage BCLC 0 and A HCCs with a diameter of up to 3 cm.. · For HCCs with a diameter between 3 and 5 cm, a combination of TACE and RFA or MWA is recommended. This combination therapy yields results comparable to those ofsurgical resection in terms of overall survival.. · Due to insufficient evidence, alternative ablation methods have only been used in individual cases and within the framework of studies. However, nonthermal methods, such as IRE, IBT, and, most recently, ECT, are a reasonable alternative for ablation of HCCs adjacent to large blood vessels and bile ducts because they cause significantly lessdamage to these structures than thermal ablation methods.. · Luerken L, Haimerl M, Doppler M et al. Update on Percutaneous Local Ablative Procedures for the Treatment of Hepatocellular Carcinoma. Fortschr Röntgenstr 2022; 194: 1075 - 1086.

Die neue internationale Sepsis-Leitlinie der Surviving Sepsis Campaign 2021

The new Surviving Sepsis Campaign (SSC) guideline was substantially revised in 2021. These updated recommendations are intended to guide intensivists in providing adequate care to adult patients with sepsis or septic shock. In particular, the current SSC guideline emphasizes early recognition and stringent management in the first hours after the onset of sepsis. In particular, the implementation of acute interventions should help to improve the chances of survival of sepsis patients.This article summarizes the most important recommendations for acute therapy and presents them as a comparative overview to the previous SSC guideline and the German S3 guideline. This should allow the reader to adopt the knowledge from the new guideline into clinical practice as quickly as possible in order to improve the quality of treatment of patients with sepsis or septic shock.

Future concepts for neoadjuvant and adjuvant treatment of (resectable) pancreatic cancer

Pancreatic cancer still has a very unfavorable prognosis. This is true even for the comparably small group of patients (maximum 15%) who are diagnosed with a clearly resectable tumor. The article provides information on the current statements of the S3 guidelines on adjuvant and neoadjuvant treatment of resectable pancreatic cancer and describes adjuvant and neoadjuvant treatment strategies. Furthermore, the article pursues the questions of if and for whom a total neoadjuvant treatment is suitable and which options of a personalized treatment are available for resectable pancreatic cancer.

Practice-guided Presentation of the German S3 Guideline "Strategies to Warrant Rational In-hospital Use of Antibiotics"

The current S3 guideline entitled "Strategies to warrant rational in-hospital use of antibiotics" summarizes evidence-based antibiotic stewardship (ABS) measures that aim to improve clinical outcomes and prevent development and spread of microbial resistance in German hospitals. Most important prerequisite for efficiency and safety of ABS programs is sufficient staffing capacity as well as reliably operating surveillance of (i) pathogens, (ii) antimicrobial resistance and (iii) consumption of antimicrobials. ABS teams require authorization by hospital institutions as units exclusively responsible for antimicrobial audits and implementation of anti-infective interventions. Clinicians should be regularly granted access to in-hospital training programs delivered by ABS experts. Finally yet importantly, the current S3 guideline also highlights future goals, e.g., the structured involvement for nurses in ABS-guided infection management or the promotion of ABS programs in the outpatient sector and in veterinary medicine.

Multiparametric MRI of the prostate

Multiparametric magnetic resonance imaging (mpMRI) is an integral component of prostate cancer diagnostics. According to the S3 guidelines on prostate cancer, mpMRI should be used for the primary diagnostics of prostate cancer as well as in active surveillance (AS). Basically, mpMRI consists of high-resolution T2-weighted (T2w) sequences, diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) sequences, which in turn are the basis for structured reporting according to the prostate imaging reporting and data system (PI-RADS) classification.

Chirurgische Therapie des Pankreaskarzinoms – was gibt es Neues?

The incidence of pancreatic ductal adenocarcinoma is continuously increasing and will become the second leading cause of cancer-related death in Europe and the USA by 2030. With a5-year overall survival rate of less than 10% the prognosis remains poor. So far surgical tumor resection remains the only curative treatment option, which is now partially supported by multimodal neoadjuvant and adjuvant therapy concepts. Due to the aggressive tumor biology patients with advanced pancreatic cancer in particular can profit from these multimodal therapy concepts. Additionally, in recent years surgical treatment was optimized, the criteria for tumor resectablity were defined and minimally invasive surgery was widely introduced. This review article summarizes the newest developments and the new German S3 guidelines concerning surgery of pancreatic cancer.

Important recommendations of the German-Austrian S3 guidelines on management of extracranial carotid artery stenosis

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. 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. 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). 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.

Überblick über relevante klinische Empfehlungen aus der neuen S3-Leitlinie „Akute und chronische Pankreatitis“

Acute pancreatitis is a primary sterile inflammation of the pancreas, which is characterized by an unphysiological enzyme activation. This leads to an inflammatory reaction with edema, vascular damage and cell decay. The first German interdisciplinary S3 guidelines on chronic pancreatitis were published in 2012. Under the auspices of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) and with the participation of various societies and patient representatives, the guidelines were recently revised and extended, Comprehensive S3 guidelines on acute and chronic pancreatitis were compiled and agreed by consensus. This article presents the important clinical aspects on acute pancreatitis from these guidelines in a compact form and the recommendations are justified.

Radiologische Aspekte der neuen deutschen S3-Leitlinie zum hepatozellulären Karzinom und biliären Karzinomen im internationalen Vergleich

The updated German S3 guideline "Diagnostics and therapy of hepatocellular carcinoma and biliary carcinomas" covers two tumor entities. The original guideline published in 2013 focusing only on the diagnosis and therapy of hepatocellular carcinoma (HCC) has been expanded to include intrahepatic cholangiocarcinoma. These guidelines were developed within the framework of the guideline program on oncology of the Scientific Medical Society e. V. (AWMF), the German Cancer Society (DKG) and German Cancer Aid Society (DKG) under the auspices of the German Society for Digestive and Metabolic Diseases (DGVS). In addition to updated recommendations regarding histopathology, radiological diagnostics and treatments, the main innovations of the revised guidelines on HCC include acomplete revision of the section on the systemic therapeutic approach in advanced stages of the disease. This article presents the significance of the current recommendations for diagnostic and interventional radiology in comparison to other national and international guidelines and should serve to improve the quality of patient care through more widespread dissemination.

Axial spondyloarthritis : Update on management based on the interdisciplinary S3 guidelines on axial spondyloarthritis including early forms and ankylosing spondylitis

This review article presents the innovations in the update of the S3 guidelines on axial spondylarthritis. The total of eight new recommendations address the areas of the consideration of differential diagnoses, coordination of comorbidity management, including a vaccination strategy, treatment targets, safety of nonsteroidal anti-inflammatory drugs (NSAID), treatment response to biological disease-modifying antirheumatic drugs (bDMARD) and discontinuation strategies when remission has been achieved. In this article the authors deal particularly with the areas of early diagnosis and referral as well as exercise therapy and drug treatment.

Diagnosis, Therapy and Follow-up of Cervical Cancer. Guideline of the DGGG, DKG and DKH (S3-Level, AWMF Registry No. 032/033OL, May 2021) - Part 1 with Recommendations on Epidemiology, Screening, Diagnostics and Therapy.

Aim This update of the interdisciplinary S3 guideline on the Diagnosis, Therapy and Follow-up of Cervical Cancer (AWMF Registry No. 032/033OL) was published in March 2021. This updated guideline was funded by German Cancer Aid (Deutsche Krebshilfe) as part of the German Guideline Program in Oncology. The guideline was coordinated by the German Society of Gynecology and Obstetrics ( Deutsche Gesellschaft für Gynäkologie und Geburtshilfe , DGGG) and the Working Group on Gynecological Oncology ( Arbeitsgemeinschaft Gynäkologische Onkologie , AGO) of the German Cancer Society ( Deutsche Krebsgesellschaft , DKG). Method The process of updating the S3 guideline dating from 2014 was based on an appraisal of the available evidence using the criteria of evidence-based medicine, adaptations of existing evidence-based national and international guidelines or - if evidence was lacking - on a consensus of the specialists involved in compiling the update. After an initial review of the current literature was carried out according to a prescribed algorithm, several areas were identified which, in contrast to the predecessor version from September 2014, required new recommendations or statements which took account of more recently published literature and the appraisal of the new evidence. Recommendations The short version of this guideline consists of recommendations and statements on the epidemiology, screening, diagnostic workup and therapy of patients with cervical cancer. The most important new aspects included in this updated guideline include the newly published FIGO classification of 2018, the radical open surgery approach for cervical cancers up to FIGO stage IB1, and use of the sentinel lymph node technique for tumors ≤ 2 cm. Other changes include the use of PET-CT, new options in radiotherapy (e.g., intensity-modulated radiotherapy, image-guided adaptive brachytherapy), and drug therapies to treat recurrence or metastasis.

Dealing with Desire to Die in Palliative Care

Dealing with Desire to Die in Palliative Care Abstract. In the course of new legal regulations, the question of how to deal with desire to die is the focus of current professional debates. From the perspective of palliative care, a desire to die should not be thought of only as the wish for assisted suicide, but should be recognised in all its possible forms and facets. An open, respectful, and interested approach towards patient perspectives is therefore essential. Goals for dealing with desire to die are formulated within the S3 guideline "Palliative care for patients with incurable cancer". Support for the implementation of such goals is provided by trainings on the topic and a clinical guideline for the discussion of a potential desire to die. Open communication about the topic primarily helps to shift the focus from taking immediate action towards a widening of perspectives, a slowing of the process and the opening of an emotional space. Decisions regarding next steps can then be made based on a richer understanding of possible underlying concerns and expectations related to desire to die. These steps can include pain management and the treatment of depression to reduce suffering associated with a desire to die. Measures may also consist of foregoing or terminating life-prolonging measures. If patients have a serious and persistent wish for assisted suicide, the existence of such a wish should be recognized and addressed appropriately.

Poly(ADP-ribose) polymerase (PARP-)inhibitors as genetically based precision therapy in metastatic castration-resistent prostate cancer (mCRPC)

With PARP inhibitors, the therapeutic landscape for metastatic castration-resistant prostate cancer (mCRPC) has been expanded by a new substance class since November 2020. Currently, the indication for this innovative therapy requires the presence of a mutation in one of the BRCA1/2 genes and prior hormonal therapy. This short review explains the molecular background and summarizes current clinical trials on PARP inhibition-also in combination with other therapy strategies. In view of positive data from the cited studies and the relatively high proportion of patients with "actionable" mutations, the personalized therapy concept of BRCA1/2 mutation-dependent PARP inhibition for mCRPC is now reflected in various guidelines including S3 guidelines.

S3 guideline Allergy Prevention.

S3 guideline Allergy Prevention.

Irritable bowel syndrome and functional dyspepsia : Diagnosis and treatment

Irritable bowel syndrome (IBS) and functional dyspepsia are chronic diseases of the digestive tract that challenge both patients and physicians due to their difficult diagnosis and limited treatment options. The international RomeIV diagnostic criteria are commonly used for research purposes. For IBS, the diagnostic criteria based on the German S3 guideline offer aless complicated alternative for everyday clinical practice. Athorough history and basic diagnostic work-up are essential for diagnosis, as reliable biomarkers are still lacking. Clinical manifestations of both disorders are variable, and it has been useful to allocate subtypes based on leading symptom clusters; these may facilitate the choice of diagnostic tests as well as symptomatic treatment approaches. Used correctly, the combination of available drug (mostly off-label) and non-drug options can help to reduce symptoms and improve quality of life.

Diagnostics and prognostic evaluation in renal cell tumors: the German S3 guidelines recommendations.

The German guidelines on renal cell carcinoma (RCC) have been developed at highest level of evidence based on systematic literature review. In this paper, we are presenting the current recommendations on diagnostics including preoperative imaging and imaging for stage evaluation as well as histopathological classification. The role of tumor biopsy is further discussed. In addition, different prognostic scores and the status of biomarkers in RCC are critically evaluated.

Interdisciplinary recommendations for the treatment of advanced renal cell carcinoma

In the treatment of advanced renal cell carcinoma, anti-VEGFR tyrosine kinase inhibitors (TKI) have been replaced mostly by immunotherapy combinations with checkpoint inhibitors (CPI), especially in first line therapy. Due to these novel therapies, the prognosis of patients has been improved further. In pivotal studies a median overall survival of 3-4 years has been achieved. TKI monotherapy remains important for patients with low risk, a contraindication against immunotherapy and with regard to the SARS-CoV-2 pandemic.Selection of the correct first line therapy is difficult to answer because there are two CPI-TKI combinations and one CPI-combination. Temsirolimus and the combination bevacizumab + interferon alfa have become less important. In second line therapy, nivolumab and cabozantinib have demonstrated superior overall survival compared to everolimus. Furthermore, the combination of lenvatinib + everolimus and axitinib are approved treatment options in the second line and further settings. TKI are an option as well, but they have lower supporting evidence. Everolimus has been replaced in the second line setting by these new options. Biomarkers are not available. The German S3 guideline has been updated recently to give better orientation in clinical practice.The question of the optimal sequence is still unanswered. Most second line options were evaluated after failure of anti-VEGF-TKI, but these are only applicable for a minority of patients.The purpose of an interdisciplinary expert meeting in november 2020 was to debate which criteria should influence the therapy. The members discussed several aspects of treating patients with advanced or metastatic RCC, including the SARS-CoV-2 pandemic. As in previous years, the experts intended to provide recommendations for clinical practice. The results are presented in this publication.

Sepsis in out-of-hospital emergency medicine

HintergrundDie Sepsis ist eine notfallmedizinische Herausforderung – denn diese lebensbedrohliche Organdysfunktion, verursacht durch eine dysregulierte Wirtsantwort auf eine Infektion, präsentiert sich in vielfältiger Ausprägung und wird deshalb häufig erst zu spät erkannt.FragestellungDie kürzlich publizierten „surviving sepsis campaign“-Guidelines und die deutsche S3-Leitlinie geben Empfehlungen zur Diagnostik und Therapie der Sepsis im intrahospitalen bzw. intensivmedizinischen Setting, gehen jedoch nicht explizit auf den Bereich der prähospitalen Notfallmedizin ein. Ziel der Arbeit ist es, die Evidenzlage im Hinblick auf die prähospitale Versorgung von Patienten mit Verdacht auf Sepsis herauszuarbeiten und daraus Handlungsoptionen für den Notarzt- und Rettungsdienst abzuleiten.DiskussionDie Therapie der Sepsis und des septischen Schocks wird in Bündeln zusammengefasst, wobei das erste idealerweise innerhalb der ersten Stunde abgeschlossen sein soll – analog zum Konzept der „golden hour“ bei anderen notfallmedizinischen Entitäten wie der Traumaversorgung. Die prähospitale Therapie fokussiert sich auf die Sicherung der Vitalparameter gemäß ABCDE-Schema, wobei insbesondere der Volumentherapie ein hoher Stellenwert zukommt. Die weiteren Maßnahmen des „1 h bundle“, wie Laktatmessung, Gewinnung mikrobiologischer Proben und Beginn einer antiinfektiven Therapie, sind regelhaft erst in der Klinik möglich. Ziel ist eine schnellstmögliche Fokussanierung, wofür die Auswahl und Vorabinformation einer geeigneten Zielklinik zur Initiierung und Bahnung der weiteren klinischen Diagnostik- und Behandlungspfade, eine strukturierte und gezielte Übergabe sowie regelmäßige Fortbildung erforderlich sind.