Departments In Germany Research Articles

Associated Findings and Complications of Retroperitoneal Fibrosis in 204 Patients: Results of a Urological Registry

We studied the frequency of associated findings and complications of retroperitoneal fibrosis in a large clinical collective of urological patients. All urology departments in Germany were invited to participate in a registry of patients with retroperitoneal fibrosis, for which a data sheet with more than 200 questions was developed. As of March 2010 a total of 204 patients were registered. The male-to-female ratio was 2.1:1 and the average age at onset was 55.6 years. In 123 cases (60.3%) the diagnosis was confirmed by histopathology. Coexisting autoimmune diseases were found in 9.8% of patients, consisting mainly of thyroid disorders. Coexisting fibrosis was detected in 3.4% of the patients and 73.9% of those queried were active smokers. Of 176 patients for whom data on therapy were available 123 received monotherapy and 41 received combination therapy for a mean of 12.1 months (12 received none), while 87 underwent a total of 103 operative procedures. Hydronephrosis was the most frequent complication in 95.6% of patients. Atrophic kidney from undetected hydronephrosis appeared in 46 patients (22.5%) and in 4 bilateral damage necessitated dialysis. Complications from vascular obstruction were observed in 27.5% of patients. Large bowel obstruction requiring colostomy occurred in 4 patients (2.0%). Patients with retroperitoneal fibrosis often first present to urology departments upon referral for hydronephrosis. In this series at least 1 kidney appeared to be irreversibly damaged in more than 20% of patients. Urologists should be mindful of the role of smoking role as a risk factor, complications arising from vascular and large bowel obstructions, and the possible association of retroperitoneal fibrosis with autoimmune disease.

Parry-Romberg Syndrome with chronic focal encephalitis: Two cases

Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany Department of Neuropathology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany Department of Neurosurgery, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany Department of Epileptology, University of Bonn Medical Centre, Germany

No inconsistent trial assessments by NICE and IQWiG: different assessment goals may lead to different assessment results regarding subgroup analyses

Ralf Bender*, Armin Koch, Guido Skipka, Thomas Kaiser, Stefan Lange Department of Medical Biometry, Institute for Quality and Efficiency in Health Care (IQWiG), D-51105 Cologne, Germany Institute for Biometry, Centre for Biometry, Medical Informatics and Medical Technology, Hannover Medical School, D-30625 Hannover, Germany Department of Drug Assessment, Institute for Quality and Efficiency in Health Care (IQWiG), D-51105 Cologne, Germany Institute Management, Institute for Quality and Efficiency in Health Care (IQWiG), D-51105 Cologne, Germany

Intravenous lacosamide for treatment of status epilepticus

Treatment of established status epilepticus (SE) requires immediate intravenous anticonvulsant therapy. Currently used first-line drugs may cause potentially hazardous side effects. We aimed to assess the efficacy and safety of intravenous lacosamide (LCM) in SE after failure of standard treatment. We retrospectively analyzed 39 patients (21 women, 18 men, median age 62 years) from the hospital databases of five neurological departments in Germany, Austria and Switzerland between September 2008 and January 2010 who were admitted in SE and received at least one dose of intravenous LCM. Types of SE were generalized convulsive (n = 6), complex partial (n = 17) and simple partial (n = 16). LCM was administered after failure of benzodiazepins or other standard drugs in all but one case. Median bolus dose of LCM was 400 mg (range 200-400 mg), which was administered at 40-80 mg/min in those patients where infusion rate was documented. SE stopped after LCM in 17 patients, while 22 patients needed further anticonvulsant treatment. The success rate in patients receiving LCM as first or second drug was 3/5, as third drug 11/19, and as fourth or later drug 3/15. In five subjects, SE could not be terminated at all. No serious adverse events attributed to LCM were documented. Intravenous LCM may be an alternative treatment for established SE after failure of standard therapy, or when standard agents are considered unsuitable.

A 14-year-old girl with a vesicle on her finger and lymphadenitis

Department of Pediatric Surgery, University of Heidelberg, Heidelberg, Germany German Consultant Laboratory for Poxviruses, Robert Koch Institute, Berlin, Germany Public Health Service Rhein Neckar Kreis, Heidelberg, Germany Department of Infectious Diseases, Virology, University of Heidelberg, Heidelberg, Germany Institute of Pathology, University of Heidelberg, Heidelberg, Germany Chemisches und Veterinaruntersuchungsamt, Karlsruhe, Germany Department of Pediatrics, University of Heidelberg, Heidelberg, Germany

Cost of Illness and Drivers of Cost in Atrial Fibrillation in Sweden and Germany

Atrial fibrillation (AF) is an important public health problem in European countries. AF is associated with increased morbidity and mortality, e.g. from heart failure and thromboembolic events. Little data have previously been presented regarding the costs of treatment in patients with AF. To estimate total direct and indirect costs in patients with AF in Sweden and Germany, and to identify determinants of total costs. A cross-sectional observational study was conducted through surveys to patients and their treating physician in primary care and in hospital outpatient cardiology departments in Sweden and Germany. A total of 922 patients with AF as diagnosed in clinical practice were enrolled and completed the study. Data were collected on medical history, treatment, medical and non-medical resource use, and employment status. Costs (year 2005 values) were calculated by multiplying resources used with prices specific for Sweden and Germany, respectively. Total annual costs per patient were €7241 in Sweden and €5586 in Germany. Slightly less than 70% of total costs were judged as being AF related in both countries. Costs of AF-related medication were about 2% of total costs in both countries. In a generalized regression model, costs were found to increase with age, but were lower in patients aged>65 years than in those aged<or=65 years, due to the absence of indirect costs in older patients. Costs were highest in patients with persistent AF and lowest in those with permanent AF. Co-morbidities with a significant influence on costs included coronary heart disease, cerebrovascular disease, heart failure and asthma. Current costs in AF patients are driven by the consequences of AF, while costs for specific treatments for AF are low. The addition of new, effective and safe treatment options could potentially reduce overall healthcare costs in AF.

Patient Information and Decision Aids in Oncology: Need for Communication Between Patients and Physicians

TO THE EDITOR: In their recent contribution to Journal of Clinical Oncology, Brace et al report on the knowledge and opinions of physicians caring for patients with cancer in the province of Ontario, Canada, about patient decision aids. Decision aids have been defined as “interventions designed to help people make specific and deliberative choices among options by providing information about the options and outcomes that is relevant to a person s health status.” Such tools play a role in assisting patients in making informed decisions about specific treatment options (eg, surgery v radiotherapy v watchful waiting in early-stage prostate cancer) and also in opting for or against cancer screening procedures. In their questionnaire survey, Brace et al found that, of 477 responders, 69% were aware of patient decision aids and 24% (40% of responding medical oncologists) actually used decision aids in their practices. Brace et al must be congratulated for collecting this comprehensive data set on the oncologists’ perspective on this important topic. However, it is possible that the rates of decision aid use by patients may actually be higher than suggested by the percentages for physicians responding to the questionnaire. Access to diseasespecific patient decision aids is provided freely on the Internet, and patients may make use of these tools without discussing them with their treating oncologists. We have been interested in patterns of patient information (eg, the importance of specific media or the rate of Internet use to obtain such information) in radiation oncology. In two independent crosssectional surveys of patients undergoing radiotherapy at university radiation oncology departments in Germany in the years 2000 and 2008, we found rates of 21% and 41%, respectively, of patients with cancer who had obtained information about the disease or its treatment via the Internet. Importantly, of those who received information via the Internet, only 24% (2000 study) and 39% (2008 study) stated that they had discussed the information with their treating physicians. Applying these findings to the physician data on decision aids, which may be limited by different settings and cultural backgrounds, one could speculate that the actual use of decision aids by patients with cancer may be much higher than reflected by the data of Brace et al. A previous meta-analysis of randomized controlled trials of the effects of cancer-related decision aids suggested that the knowledge of patients with cancer is increased, whereas their anxiety is not—an effect that was most clearly shown for screening decisions. Improving communication between patients and oncologists about information, including decisions aids, obtained via the Internet should serve two purposes: to provide patients with access to objective additional information that is helpful in the decision-making process and to integrate this knowledge into the patient-physician interaction.

Helmet use in winter sport activities—attitude and opinion of neurosurgeons and non-traumatic-brain-injury-educated persons

During the last winter season, some fatal sport injuries with severe traumatic brain injury (TBI) prompted major discussions about protective helmet use. Although ski helmets reportedly lead to a 60% decrease of risk to incur TBI, little is known about the distribution of helmet users and which factors are crucial for the decision to wear a helmet. Especially, it is unknown whether knowledge or experience concerning TBI in winter sports influences the use of helmets, as well as the attitude and opinion of people. Since treatment of TBI is a major field in neurosurgery, 55 neurosurgical departments (NS) in Germany, Switzerland and Austria were addressed and asked to answer anonymous questionnaires. A "non-trauma-educated" control cohort (NTP) was interviewed in ski resorts in Austria as well as sports equipment stores in Germany. Questionnaires were returned by 465 NS and 546 NTP. Half of NS and NTP wore helmets in winter sports. Although some interviewees showed cognitive dissonant behaviour, experience in TBI after ski or snowboard accidents significantly affected the decision to wear helmets. After the fatal ski accidents, and increased media coverage 15.4% NS and 13.2% NTP bought their helmet. Furthermore, incidence of helmet use in children was correlated with the actual use and disposition of their parents to make the use of helmet compulsory. This study indicates that brain-trauma education affects ones attitude and opinion concerning protective helmet use in winter sports. However, without neglecting educational measures, emotional arguments should be added in the promotion of helmets to make them a popular integral part of winter sport outfits.

AP-1/σ1B-adaptin mediates endosomal synaptic vesicle recycling, learning and memory

AP-1/σ1B-adaptin mediates endosomal synaptic vesicle recycling, learning and memory

Telomerase-deficiency-related bone loss is caused by intrinsic impairment of mesenchymal stem cell (MSC) functions and increased osteoclastogenesis due to pro-inflammatory micro-environment

Telomerase-deficiency-related bone loss is caused by intrinsic impairmentofmesenchymal stemcell (MSC) functions and increased osteoclastogenesis due to pro-inflammatory micro-environment H. Saeed, B.M. Abdallah, N. Ditzel, P. Catala-Lehnen, W. Qiu, M. Amling, M. Kassem Department of Endocrinology and Metabolism, Endocrine Research Laboratory (KMEB), Odense University Hospital & University of Southern Denmark, Odense, Denmark Universitats klinikum, Hamburg-Eppendorf, Hamburg, Germany Department of Endocrinology and Metabolism, Endocrine Research Laboratory (KMEB), Odense University Hospital & University of Southern Denmark, Odense, Odense, Denmark

The impact of guidelines on the treatment of endometrial cancer in Germany: A nationwide analysis of the AGO in 2006 and 2009.

e15533 Background: The AGO established and updated guidelines on the assessment and treatment of endometrial cancer (EC) in 2006 and 2009. This prospective study tries to elucidate how patients with endometrial cancer are cared for in daily routine in Germany and to find out to which extent modification of a guideline actually changes treatment behavior on a nationwide basis. Methods: A questionnaire has been established and sent to gynecological departments in Germany. It comprises documentation of the use of peritoneal washing cytology (PWC), lymphadenectomy (LNE), adjuvant chemotherapy (CT) and adjuvant endocrine treatment (ET). The guidelines recommend performance of PWC and pelvic/paraaortic LNE. Only in very early EC disease LNE can be omitted. CT is recommended for extra-uterine disease of type I EC and for all type II EC. The guideline updated in 2009 extended the recommendation of CT by some high-risk cases of uterine disease. ET is not recommended. Results: 178/500 (35.6%) questionnaires in 2006 and 258/775 (33.3%) in 2009 were returned to our unit. A PWC was obtained in 86.9% and 94.6% in 2006 and 2009, respectively (p = 0.008). LNE in early stage type I EC was performed more frequently in 2006 as compared to 2009 (e.g., pT1a G2: 38.6% vs. 22.9%, p = 0.001; pT1b G1 47.6% vs. 39.6%, p = 0.019). In type I EC with extra-uterine disease LNE was often not advised (pelvic LNE in 2009 and 2006: pT3 76.2% vs. 80.1% and 41.5% vs. 38.0%, respectively). In 2006 and 2009 all the other stages received pelvic LNE in about 90% (e.g., pT1b G3: 96.3% vs. 95.3%; pT2a 97.6% vs. 97.6%). In 2006 paraaortic LNE was carried out less frequently compared to 2009 (e.g., pT1b G3: 70.2% vs. 90.2%, p < 0.001; pT2a: 86.3% vs. 95.7%, p < 0.001). 48.8% in 2006 vs. 63.7% in 2009 received CT (p = 0.003). 25.7% and 15.4% underwent ET in 2006 and 2009, respectively (p = 0.012). Conclusions: Common clinical-therapeutic approaches were recommended more often according to guidelines in 2009 as compared to 2006. However, there were still important aspects in the management of EC, which did not meet the recommendations of the guideline. These findings show that a better adherence to therapeutic guidelines is still warranted. No significant financial relationships to disclose.

Attitude and Opinion of Neurosurgeons Concerning Protective Bicycle-Helmet Use

Wearing protective helmets decreases the risk of incurring traumatic brain injury (TBI) in bicycle accidents. In 2007, the German Neurosurgical Society advocated compulsory use of bicycle helmets. Although neurosurgeons are the specialists who primarily treat patients with TBI in Europe, the distribution of helmet users among neurosurgeons (NS), as well as factors that influence the decision to wear helmets and whether professional knowledge or experience in TBI influences the use or attitude concerning bicycle helmets, remains unclear. A total of 55 neurosurgical departments in Germany, Austria, and Switzerland were contacted and asked to answer anonymous questionnaires concerning helmet use and TBI experience. To compare the neurosurgical attitude with that of a "non-neurosurgical, non-TBI-educated" control group, people of the general public (PUB) were interviewed. A total of 465 NS and 546 PUB returned questionnaires, with 49.7% of the NS and 44.5% of PUB indicated that they wear helmets while bicycling. Trauma experience did effect the personal decision of whether to wear bicycle helmets. Support of compulsory use was influenced by TBI experience. Furthermore, the incidence of helmet use in children was correlated to actual helmet use and disposition of their parents to make helmet use compulsory. NS and PUB behaved in similar ways. Only half wear protective helmets, while the others show cognitive dissonant behavior. With respect to compulsory helmet use, NS are also split in half. Experience with TBI and trauma education has effects. However, education alone does not suffice in promoting the use of bicycle helmets.

Verwendung von Botulinumtoxin an HNO-Kliniken in Deutschland

There are no regional data about the prevalence and use of botulinum toxin (BoNT) in otorhinolaryngology (ORL) departments in Germany. In order to obtain an overview of the current applications of BoNT in ORL departments a survey was carried out. Standardized multi-choice questionnaires were mailed to 150 ORL departments. In the analysis a differentiation was made between university and regional departments. Also an analysis of the whole collective of respondent hospitals was carried out. The most commonly treated indication is the Frey syndrome followed by hypersalivation due to a salivary fistula after parotidectomy, dysphagia, aesthetic application and laryngeal dystonia. The rate of return was 62% and 75% of all responding hospitals use BoNT as a therapeutic option, especially where "off-label-use" indications are concerned (15 out of 20 indications or 75%). BoNT is widely used as a therapeutic option with an increasing trend. Due to different applications a schedule of hospitals would be helpful in order to be able to find the nearest hospital for the appropriate indications.

Response to Hollis-Moffatt et al.

1Department of Human Genetics, RWTH Aachen, Aachen, Germany 2Department of Medicine II–Grosshadern, University of Munich, Munich, Germany 3Department of Preventive Dentistry and Periodontology, University of Munich, Munich, Germany Correspondence: Stephan Brand, MD, Department of Medicine II–Grosshadern, Ludwig-Maximilians-University Munich, D-81377 Munich, Germany. E-mail: [email protected]

Die operative Weiterbildung an deutschen orthopädischen und traumatologischen Kliniken

Training in surgical skills is not at its best in German hospitals in comparison to other countries. There is no detailed curriculum describing which operations a resident has to learn at which stage of his training as in Switzerland or Denmark. We aimed to find out how many typical operations are performed by trainees/residents in orthopaedic surgery. We performed a survey at Orthopeadic and Trauma Departments in Germany to measure the percentage of operations (knee arthroscopies, shoulder arthroscopies and knee arthroplasties) which are performed by trainees and residents. Retrospective data were evaluated. Out of 35 654 knee arthroscopies, 49.4% were performed by the head of department or senior consultants, 27.6% by junior consultants and 26.9% by trainees. A total of 30,642 shoulder arthroscopies was analysed. 78.4% were operated on by the head of department or senior consultants, 18.3% by junior consultants and 6.9% by trainees. We evaluated 31,138 knee arthroplasties, 80% were operated by the the head of department or senior consultants, 14% by junior consultants and 7% by trainees. Surgical training is still not at its best for trainees. Further improvement is necessary to create a transparent training environment for younger surgeons.

Prevalence and risk factors for early postpartum anemia

Objective To assess the prevalence and evaluate the most important risk factors for early postpartum anemia. Study design The perinatal process data of 43 807 women delivering between 1993 and 2008 (90.1% of all deliveries) in the largest university obstetric department in Germany were analyzed, and the associations of Hb < 8 g/dl with maternal characteristics, pregnancy risks, delivery mode and estimated delivery blood loss were calculated. Multivariable logistic regression models were applied to compute odds ratios. Additionally, the impact of these risk factors for delivery blood loss was estimated with multivariable linear regression analysis. Results Twenty-two percent of mothers had Hb < 10 g/dl, and 3% had Hb < 8 g/dl. The adjusted odds ratios (OR) for Hb < 8 g/dl were 4.8 ( p = 0.001) for placenta previa, 2.9 ( p < 0.001) for mothers of African origin, 2.7 ( p < 0.001) for diagnosed anemia in pregnancy, 2.2 ( p < 0.001) for multiple pregnancy, and 2.1 ( p = 0.021) for bleeding in late pregnancy. However, the delivery blood loss was the most important risk factor for postpartum anemia. The adjusted OR for an estimated blood loss of 500–1000 ml was 15.3 ( p < 0.001), and for a loss of >1000 ml was 74.7 ( p < 0.001). Conclusion The estimated obstetric blood loss is the most important risk factor for severe postpartum anemia, and the volume of blood lost is especially high in cesarean deliveries, which should be considered when electing delivery procedures. Also, measures to boost iron stores in pregnancy should be established.

Awareness and perception of intra-abdominal adhesions and related consequences: survey of gynaecologists in German hospitals

Objective Intra-abdominal adhesion formation after abdominal surgery is the most common postsurgical complication, and the consequences are a considerable burden for patients, surgeons and health systems. Since a wide variety of factors influence adhesion formation, it is difficult to define clear guidelines on how to reduce adhesion formation in daily practice. Given this dilemma, this study assessed the awareness and perception of adhesion formation among gynaecologists in Germany in order to define a baseline for further research and education. Study design The Clinical Adhesion Research and Evaluation (CARE) group of the University of Giessen designed a questionnaire that was sent to the heads of all gynaecological departments in Germany. The director or one of the surgical consultants was asked to complete the questionnaire and return it for evaluation. Results The completed questionnaire was returned by 279 of 833 gynaecological departments. Interviewed surgeons expected adhesions to form in 15% of cases after laparoscopy and 40% after laparotomy. Before surgery, 83.1% of the respondents told their patients about the risk of prior adhesion formation. More than 60% believed that postsurgical adhesion accounts for major morbidity. Infections within the abdomen, previous surgery and extensive tissue trauma were thought to have the most influence on adhesion formation. Risk of adhesion formation was thought to be highest in endometriosis and adhesiolysis surgery. The respondents agreed on performing adhesiolysis in symptomatic but not in all patients. Only 38.4% used adhesion reduction agents regularly. A total of 65.1% of a repertoire of adhesion prevention agents were familiar to the interviewed surgeons. Only 22.0% of them used anti-adhesion products in clinical practice. In general, the respondents were uncertain whether these products play an important role in adhesion reduction, represented by a range of 1.97 ± 0.98% on a scale from 0 to 4. Conclusions Even though postoperative adhesions are recognized as a major cause for morbidity, and it is widely agreed that infections, extensive tissue trauma and surgery lead to adhesion formation, there is uncertainty about the treatment and prophylactic strategies for dealing with adhesions. This dilemma reflects the awareness and perception of gynaecologists in Germany and is an initial point for further research.

Health‐related quality of life in patients with Gilles de la Tourette's syndrome

To investigate the health-related quality of life (HrQoL) of adult patients with Gilles de la Tourette's syndrome (GTS) in Germany. HrQoL was evaluated in 200 adult patients with GTS (Mean age: 34.9 +/- 11.8 years). Patients were recruited from three outpatient departments in Germany and completed a semi-structured, self-rating interview. HrQoL was measured using the EQ-5D. Depression was assessed using the Beck's depression inventory (BDI) and clinical symptoms using the Yale Tourette syndrome symptom list (TSSL) and the Shapiro Tourette-syndrome severity scale (STSSS). Multivariate regression analyses were performed to identify independent predictors of HrQoL. Patients with GTS proved to have a worse HrQoL than a sample from the general German population. The domains most affected were anxiety/depression (57.1%), followed by pain/discomfort (47.5%), usual activities (38.4%), mobility (14%), and self-care (6.6%). The mean EQ-5D visual analog scale (EQ-VAS) was 65.4 +/- 21.9. The patients had a mean BDI score of 12.3 +/- 9.9, which was considerably worse compared to a healthy group who had a score of 6.45 +/- 5.2. The mean STSSS value was 3.2 +/- 1.1. In multivariate analyses, depressive symptoms contributed considerably, whereas the severity of symptoms as well as age only contributed minimally to HrQoL in the model (R(2) = 0.54). HrQoL is considerably reduced in adult patients with GTS. The main independent factors for determining HrQoL were depression, severity of symptoms, and age. Although, treatment of tics is important, co-morbidities such as depression should be diagnosed and treated vigorously.

Involvement of the human ventrolateral thalamus in the control of visually guided saccades

Department of Neurology, Medical Faculty, RWTH University, Aachen, Germany Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada Vision Science Research Program, Toronto Western Research Institute, Toronto, Ontario, Canada Department of Physiology, University of Toronto, Toronto, Ontario, Canada Division of Neurology, University Health Network, University of Toronto, Toronto, Ontario, Canada Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada

GAPO syndrome associated with craniofacial vascular malformation

GAPO Syndrome Associated With Craniofacial Vascular Malformation Gregor Castrillon-Oberndorfer, Robin Seeberger, Claire Bacon, Michael Engel, Friedrich Ebinger, and Oliver Christian Thiele* Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, Heidelberg, Germany Molecular Division, Department of Human Genetics, University Hospital Heidelberg, Heidelberg, Germany Department of Pediatric Neurology, University Hospital Heidelberg, Heidelberg, Germany