Aktuelle Epidemiologie der Tuberkulose weltweit,in Europa und in Deutschland

Background

Tuberculosis remains one of the most important infectious diseases worldwide. For 2011 the World Health Organization estimated that there were 8.7 million new cases of tuberculosis and 1.4 million deaths from tuberculosis.

Objectives

This article gives an overview on the current tuberculosis (TB) situation worldwide, in Europe as well as in Germany. Special attention is given to drug resistance and the HIV and tuberculosis coepidemic as they strongly impact on the epidemiology of tuberculosis.

Methods

International and national epidemiological reports on tuberculosis as well as selected epidemiological studies were considered. Challenges for tuberculosis control in Germany are discussed.

Results

Globally, a slight decline in tuberculosis incidence is currently being observed. This is partly attributed to improvements in diagnostic and therapeutic care and also for HIV infected patients. However, drug resistance rates are causing concern, especially in several newly independent states of the former Soviet Union. Although tuberculosis case numbers and incidences in the European Union and the European Economic Area (EU/EEA) are comparably low, tuberculosis still represents a considerable burden of disease. In Germany, as in several other western European countries with a low incidence of tuberculosis, case numbers are stagnating and childhood tuberculosis is slightly increasing. Therefore, efforts to ensure an effective tuberculosis control cannot be allowed to wane.     

Tabakkontrolle in Deutschland und weltweit

Tobacco use is the leading preventable cause of morbidity and mortality. Several evidence-based measures including tax increases, smoke-free legislation, public information campaigns, comprehensive advertising bans, health warnings, and cessation support are available to reduce tobacco use. Although many of these measures are being adopted globally, there is still an urgent need for stringent implementation. Germany has adopted several tobacco control measures in recent years to decrease tobacco consumption; nevertheless, compared with other European countries, Germany still lags behind. Therefore, more comprehensive tobacco control measures need be adopted. Physicians should contribute to this process.     

Epidemiologie und Therapie der Lyme-Arthritis und anderer Manifestationen der Lyme-Borreliose in Deutschland

AIM OF THE STUDY: Only little is known about the epidemiology of Lyme borreliosis in Germany. As an example, it is still unclear if there are regional differences in the incidence of Lyme disease in general or of certain clinical manifestations like Lyme arthritis. Moreover, standardization of diagnostic or therapeutic procedures does not exist. Therefore, a Germany-wide questionnaire-based survey was conducted in order to achieve more epidemiological data and to obtain more information about the diagnostic and therapeutic approaches of general practitioners and specialists. METHODS: A self-designed questionnaire was distributed along with two editions of the journal "Deutsches Arzteblatt" (which is delivered to every physician in Germany) and additionally by a pharmaceutical company. During the collection period from March 1, 1998 to February 28, 1999, patients with Lyme disease were reported and information was given about site of infection, diagnostic procedures, clinical symptoms, treatment, and outcome. RESULTS: Altogether 3935 patients were reported. Their mean age was 43.4 years with the peak incidences around the ages of 10 and 60 years. 37.3% of the questionnaires were sent in by general practitioners, 17.6% by dermatologists, 15.7% by pediatricians, 9.7% by internists, and 2.7% by neurologists. 83% of the patients did not have a special infecion risk. The most frequent clinical Lyme manifestation was erythema migrans (EM), which occurred in 50.9% of the patients. 21.3% suffered from general symptoms. Of special interest, 24.5% of the patients had Lyme arthritis (14.7% mon- or oligoarthritis, 9.8% polyarthritis). Therefore, arthritis was more frequently reported than neuroborreliosis (18.4%). Only 16% of the neuroborreliosis patients and 32% of the arthritis patients remembered having had an EM. 189 patients (4.8%) with lymphadenosis cutis benigna and 100 patients (2.5%) with acrodermatitis chronica atrophicans were reported. In 80.4% of the patients, positive Lyme serology was detected. In a few cases, the diagnosis was established by isolation of borreliae, PCR or histology. 3754 patients were treated by antibiotics. The most frequently used compounds were doxycycline (50.4%), followed by ceftriaxone (22.4%), amoxicillin (13.6%), penicillin (7%), and erythromycin (4.2%) with differences depending on clinical manifestations and specialization of the prescribing physician. In less than 10% of the cases, not evaluated or recommended therapeutic procedures were performed. DISCUSSION: Lyme disease is endemic throughuot Germany. The most frequent manifestations are EM, followed by Lyme arthritis and neuroborreliosis. Less than one third of patients suffering from disseminated or chronic Lyme disease remembered an EM. Most of the physicians taking part in this survey follow treatment recommendations concerning choice of antibiotics and treatment durations.     

Epidemiologie und Komorbiditäten der Adipositas in Deutschland

Excess weight and obesity are a problem of huge quantitative importance both in Germany and worldwide. Serial data obtained in the US and Germany show a substantial increase in the prevalence in recent decades. Today the prevalence in Germany totals approximately 40% for overweight and about 20% for obesity. At the same time the incidence of the metabolic syndrome and type-2 diabetes is increasing. Epidemiological data show a prevalence of between 6% and 7% for Germany and a trend towards a further increase. Obesity and diabetes are frequently diagnosed together and abdominal obesity in particular points to the later development of diabetes. The relative frequency of these entities appearing together, however, is not static, as demonstrated by the comparison with Asian countries, where the prevalence of diabetes is substantially higher while the rate of obesity is significantly lower. Irrespective of a concomitant diagnosis of diabetes, obesity ultimately leads to increased cardiovascular morbidity and mortality, the result of which is increased drug utilization among obese versus normal-weight patients in primary care. An early preventive approach with the participation of the treating physician is therefore warranted to halt the epidemic and to reduce its consequences in terms of health.     

Epidemiologie der Tuberkulose in Deutschland

Mit 7723 Neuerkrankungen und einer Inzidenz von 9,4/100.000 Einwohner gehörte die Tuberkulose im Jahr 2002 in Deutschland zu den 5 häufigsten meldepflichtigen Infektionskrankheiten, die häufigste und wichtigste der Atmungsorgane. So macht die Lungentuberkulose rund 80% der Organmanifestationen aus. Ein Drittel der Tuberkulosepatienten ist außerhalb Deutschlands geboren, der Anteil nimmt leicht zu. Gegenüber den Vorjahren ergibt sich für 2001 eine höhere Zahl multiresistenter Erreger (global 2,7%), sie vergrößert sich bei den in den Nachfolgestaaten der Sowjetunion geborenen Kranken auf 16,5%. In der Therapie der Tuberkulose konnte in Deutschland 2001 die Zielvorgabe der WHO (>85%) nicht erreicht werden: Heilung und komplett durchgeführte medikamentöse Behandlung ergaben sich nur bei 81,1% der Kranken.     

Epidemiologie der Tuberkulose in Deutschland

In Germany tuberculosis today is the 5^th frequent infectious disease, doubtless the most important of the respiratory tract. In 2002 the incidence run to 9,4/100.000 inhabitants, 7.723 new cases were registered. In 80% lung tuberculosis was seen. One third of the patients was born outside of Germany, this part slightly increased. Compared to 2001 there was a small increase of multidrug-resistant tuberculosis, in general 2,7%. Antituberculosis drug resistance is a specific and severe problem in Eastern Europe. In patients born in the former Soviet-Union multidrug-resistance was found in 16,5% of cases. Referring to the goals of the WHO (>85%), treatment of tuberculosis in Germany wasn't fully successful: curative therapy was demonstrated only in 81,1% of the patients in 2001.     

Mobilapplikationen und Management der Hypertonie

Via the internet smartphones allow the download of applications (“Apps”) that can address various requirements of daily life. These technical advances create new opportunities to better meet needs of patients suffering from hypertension. This may apply particularly for medication adherence, blood pressure control and lifestyle-changing activities. At the moment younger users in particular are interested in such technology. From other clinical contexts it is known that text messages via cell phones improve medication adherence. A combination of a smartphone and a blood pressure measurement device with the possibility to electronically collect data is promising as the quality of data may improve. Technology interventions by mobile applications that are supported by education or an additional intervention demonstrate a beneficial impact for the reduction of physical inactivity and/or overweight and obesity. However, it is not clear what parts of the technology or interventions are effective. For future developments it will be important to reduce costs and better meet hardware and software requirements of elderly users.     

Mechanismen und Epidemiologie der Antibiotikaresistenz

Zum Thema Bakterielle Resistenz gegenüber Antibiotika ist ein weltweit zunehmendes Problem. Um eine weitere Resistenzentwicklung zu verhindern oder zumindest in Grenzen zu halten, sind Kenntnisse über die Epidemiologie und die Grundlagen der Resistenzentwicklung erforderlich. Im folgenden Beitrag werden daher die Faktoren der Ausbreitung, die genetischen Mechanismen und die biochemischen Grundlagen der Antibiotikaresistenz dargestellt. Besondere Resistenzmechanismen von klinischer Bedeutung werden beispielhaft vorgestellt.     

Epidemiologie und Therapie bakterieller Infektionen in der Geriatrie

As the elderly segment of our population expands, there is an increase of therapeutic problems considering this age group. The elderly patient is generally susceptible to infections because of the decline in host defense mechanisms that occurs with aging, and the underlying chronic diseases of these patients. Increasing numbers of elderly people are being treated in hospitals and are additionally at particular risk of acquiring nosocomial infections with antibiotic-resistant organisms. This article focuses on the epidemiological considerations, risk factors, types of infections that occur in elderly patients, and the guidelines for empiric therapy. The most common infections of the elderly are respiratory tract infection, urinary tract infection, and skin and soft tissue infection. Empirical therapy should be broader in spectrum for elderly patients since the variety of infecting bacteria tends to be greater and the choice of antimicrobial therapy must be based on risk stratification (age, medical illnesses, and severity of presentation). Many additional aspects, e.g., route of administration, drug pharmacokinetics and pharmacodynamics, drug toxicity and drug-drug interactions, compliance, and multiple underlying diseases (e.g., renal failure) must be considered in the rational selection of antibiotic regimen.     

Pulmonale Hypertonie und Rechtsherzversagen auf der Intensivstation

The management of pulmonary hypertension and right ventricular failure in hemodynamically unstable patients is one of the most challenging situations in critical care medicine. Inadequate therapy, e.g. aggressive fluid resuscitation or invasive ventilation, may even harm patients with pulmonary hypertension. Identifying the underlying etiology therefore remains the primary focus for initiating successful management of patients with decompensated pulmonary hypertension and right ventricular failure. Pulmonary embolism requires immediate restoration of pulmonary vascular patency. The body of evidence from studies is scarce and favors dobutamine, NO inhalation, and intravenous prostacyclin. However, the use of other vasoactive substances, inotropes, and supportive measures has been successful in individual patients; it should be guided by the expected effects on the pulmonary vasculature or right ventricle, and should be adapted to the patient’s concomitant diseases.     

Epidemiologie und Versorgung im Bereich der Spondylarthropathien

Within the group of inflammatory rheumatic diseases, spondyloarthropathy is the most common diagnosis after rheumatoid arthritis. Its prevalence was long underestimated. Ankylosing spondylitis (AS) and undifferentiated spondyloathropathy (uSpA) are the most common subgroups in western countries. There are still difficulties in diagnosis especially of the early forms of the spondyloarthropathies. Data of socioeconomics and therapeutic options are limited. In more recent times, researchers have started to investigate the burden of disease and the socioeconomic aspects. Better diagnostic options are available and promising new therapeutic agents, especially TNF-alpha blocking agents, have been investigated. However, further studies are urgently needed for this underestimated group of diseases and are currently being performed inside the German rheumatology network.     

Die Epidemiologie der vertebralen Osteoporose in Europa: Prävalenz, Risikofaktoren und Krankheitslast in Deutschland (EVOS)

Ohne Zusammenfassung     

Pulmonale arterielle Hypertonie bei Kollagenosen: Klinik, Epidemiologie, Pathogenese, Diagnostik und Therapie

Pulmonary arterial hypertension (PAH) is a severe vasculopathy, which is characterised by progressive narrowing and obliteration of the pulmonary arterioles and increased endothelin-1 levels. The increase of vascular resistance in the lung vessels leads to chronic pressure overload and to right heart failure, if untreated. PAH often occurs in association with rheumatic-inflammatory diseases (e.g., in 15% of patients with systemic sclerosis (SSc), especially in the limited form or in CREST patients) and determines their prognosis: in advanced stages, untreated patients die within a short period. Therefore all SSc patients, particularly the newly diagnosed ones, should be screened for PAH with echocardiography. If PAH is suspected, a right heart catheter should be performed, and if PAH is confirmed, adequate treatment should be initiated. While few years ago lung transplantation was the only option for patients with severe PAH, in recent years enormous progress was seen in drug treatment. Today prostanoids (Ventavis^®) and the endothelin receptor antagonist bosentan (Tracleer^®) are available for patients with PAH in WHO/NYHA stage III: they have substantially improved the prognosis of PAH in the last years. Since few months, also the phosphodiesterase inhibitor sildenafil (Revatio^®) is available. The combination of drugs with different mode of action will likely further improve the prognosis of PAH patients.