Socioeconomic effects of establishing a new stroke center in Central Switzerland.

BACKGROUND: Establishment of dedicated Stroke Centers has shown to be effective on the outcome of patients with acute ischemic stroke, as well as mechanical thrombectomy (MTE) in acute large vessel occlusion. The cost-effectiveness of this treatment has also been proven in several countries, but so far not in Switzerland. METHODS: We compare the pathways and economic impact of patients with acute large vessel occlusions causing acute ischemic stroke before the establishment of the stroke center and MTE in 2016 with the time afterwards in the years 2016-2020. Local data from the Swiss Stroke Registry and hospital accounting as well as economic data from a healthcare insurance company was used for evaluation in an economic model. Both payer and societal perspectives were considered, and probabilistic sensitivity analysis was undertaken to explore uncertainty. RESULTS: Establishment of a new Stroke Center in Central Switzerland increased the absolute number of thrombectomies from 0 in 2015 to 55 in 2016 to 83 in 2020, as well as the percentage of MTE in large vessel occlusions (LVO) from 50.9% in 2016 to 58.2% in 2020. Over a 15-year horizon, predicted average additional costs of CHF 7,978 were associated with the establishment of a new stroke center, as well as 0.60 quality-adjusted life-years (QALY) per patient and an additional survival of 0.59 years per patient. The calculated incremental cost-effectiveness ratio was therefore CHF 13,297 per QALY gained. When societal costs were included, the new stroke care model was predicted to dominate the old care model. Robustness of model results was confirmed via probabilistic sensitivity analysis. LIMITATIONS: The results rely on data from a single stroke center and, therefore, cannot be generalized. CONCLUSIONS: Establishment of a new Stroke Center can be cost-effective and provide better outcomes in terms of functional independence as well as quality-adjusted life-years.

[Clinical anamnestic characteristics in neurological work-related medical rehabilitation : Necessity for a qualitative identification of severe restrictions of work ability]. / Klinisch-anamnestische Charakteristika in der neurologischen MBOR : Notwendigkeit einer qualitativen BBPL-Identifikation.

BACKGROUND: Severe restrictions of work ability (SRWA) as a condition for participation in neurological work-related medical rehabilitation (WMR) have not been adequately described up to now. Similarly, the applicability of the screening instrument SIMBO-C for evaluating SRWA in neurological rehabilitation has not yet been answered conclusively. OBJECTIVE: Determination of clinical and anamnestic characteristics of neurological SRWA and assessment of the applicability of the screening instrument SIMBO-C in neurological WMR. MATERIAL AND METHODS: For the identification of SRWA clinical and anamnestic characteristics of 344 rehabilitants were routinely collected. The clinically and anamnestically determined SRWA was described quantitatively and content-analytically and correlated with SIMBO-C. RESULTS: Of the rehabilitants 66% exhibited SRWA. Apart from the established characteristics of SRWA further person and disease-specific factors were found. The SIMBO-C score was significantly higher in the group with SRWA compared to the group without SRWA (45.6 ± 18.9 vs. 31.5 ± 12.5, p < 0.001); however, 31% of the group with SRWA and 50% of the group without SRWA demonstrated a SIMBO-C score ≤ 36 points and thereby a large overlap. The profile of the clinical and anamnestic characteristics in the group with SRWA was homogeneous, regardless of the SIMBO-C score. CONCLUSION: The characteristics of neurological SRWA are mainly qualitatively shaped and may only partly be identified by SIMBO-C. A combined quantitative and qualitative approach is necessary in neurological WMR.

Why take part in personalised cancer research? Patients' genetic misconception, genetic responsibility and incomprehension of stratification-an empirical-ethical examination.

Therapeutic misconception is a well-known challenge for informed decision-making for cancer research participants. What is still missing, is a detailed understanding of the impact of "personalised" treatment research (e.g. biomarkers for stratification) on research participants. For this, we conducted the first longitudinal empirical-ethical study based on semi-structured interviews with colorectal cancer patients (n = 40) enrolled in a biomarker trial for (neo)adjuvant treatment, analysing the patients' understanding of and perspectives on research and treatment with qualitative methods. In addition to therapeutic misconception based on patients' confusion of research and treatment, and here triggered by misled motivation, information paternalism or incomprehension, we identified genetic misconception and genetic responsibility as new problematic issues. Patients mainly were not aware of the major research aim of future stratification into responders and non-responders nor did they fully acknowledge this as the aim for personalised cancer research. Thus, ethical and practical reflection on informed decision-making in cancer treatment and research should take into account the complexity of lay interpretations of modern personalised medicine. Instead of very formalistic, liability-oriented informed consent procedures, we suggest a more personalised communication approach to inform and motivate patients for cancer research.

Prognostic impact of chondroitin-4-sulfotransferase CHST11 in ovarian cancer.

Ovarian cancer (OvCa) accounts for the highest tumor-related mortality among gynecological malignancies, but the underlying mechanisms are poorly understood. Glycosaminoglycans are abundantly present in ovarian tumors, and there is rising evidence that chondroitin sulfate (CS) as well as diverse carbohydrate sulfotransferases (CHSTs), the enzymes involved in the sulfation process of these structures, plays an important role in metastatic spread of tumor cells. mRNA expression levels of CHST3/7/11/12/13/15 were compared between malignant (86 OvCas) and non-malignant tumors (6 borderline tumors and 3 cystadenomas). CHST11 and CHST15 were further chosen for Western blot analysis in a cohort of 216 OvCas. Protein expression levels were correlated with clinicopathologic prognostic parameters and survival data. A significantly higher mRNA expression of CHST11, CHST12, and CHST15 was measured in ovarian cancer samples in comparison to non-malignant ones, and the same trend was observed for CHST13. For CHST3 and CHST7, no significant differences were found between the two groups. At protein level, high CHST11 expression was independently associated with unfavorable progression-free survival (PFS; p = 0.027). A similar trend was observed for CHST15, showing a nearly significant correlation between high expression levels and shorter recurrence-free survival in patients without macroscopic residual tumor after surgery (p = 0.053). We conclude that CHSTs involved in the synthesis of CS-A and CS-E might influence ovarian cancer progression, and we suggest CHST11 as independent unfavorable prognostic factor in this entity.

New ischaemic brain lesions in cervical artery dissection stratified to antiplatelets or anticoagulants.

BACKGROUND AND PURPOSE: To determine the frequency of new ischaemic or hemorrhagic brain lesions on early follow-up magnetic resonance imaging (MRI) in patients with cervical artery dissection (CAD) and to investigate the relationship with antithrombotic treatment. METHODS: This prospective observational study included consecutive CAD patients with ischaemic or non-ischaemic symptoms within the preceding 4 weeks. All patients had baseline brain MRI scans at the time of CAD diagnosis and follow-up MRI scans within 30 days thereafter. Ischaemic lesions were detected by diffusion-weighted imaging (DWI), intracerebral bleeds (ICBs) by paramagnetic-susceptible sequences. Outcome measures were any new DWI lesions or ICBs on follow-up MRI scans. Kaplan-Meier statistics and calculated odds ratios with 95% confidence intervals were used for lesion occurrence, baseline characteristics and type of antithrombotic treatment (antiplatelet versus anticoagulant). RESULTS: Sixty-eight of 74 (92%) CAD patients were eligible for analysis. Median (interquartile range) time interval between baseline and follow-up MRI scans was 5 (3-10) days. New DWI lesions occurred in 17 (25%) patients with a cumulative 30-day incidence of 41.3% (standard error 8.6%). Occurrence of new DWI lesions was associated with stroke or transient ischaemic attack at presentation [7.86 (2.01-30.93)], occlusion of the dissected vessel [4.09 (1.24-13.55)] and presence of DWI lesions on baseline MRI [6.67 (1.70-26.13)]. The type of antithrombotic treatment had no impact either on occurrence of new DWI lesions [1.00 (0.32-3.15)] or on functional 6-month outcome [1.27 (0.41-3.94)]. No new ICBs were observed. CONCLUSION: New ischaemic brain lesions occurred in a quarter of CAD patients, independently of the type of antithrombotic treatment. MRI findings could potentially serve as surrogate outcomes in pilot treatment trials.

Attenuation of blood flow pulsatility along the Atlas slope: a physiologic property of the distal vertebral artery?

BACKGROUND AND PURPOSE: Physiologic and pathologic arterial tortuosity may attenuate blood flow pulsatility. The aim of this prospective study was to assess a potential effect of the curved V3 segment (Atlas slope) of the vertebral artery on arterial flow pulsatility. The pulsatility index and resistance index were used to assess blood flow pulsatility. MATERIALS AND METHODS: Twenty-one healthy volunteers (17 men, 4 women; mean age, 32 years) were examined with a 3T MR imaging system. Blood velocities were measured at 2 locations below (I and II) and at 1 location above the V3 segment (III) of the vertebral artery by using a high-resolution 2D-phase-contrast sequence with multidirectional velocity-encoding. RESULTS: Pulsatility and resistance indices decreased along all measurement locations from proximal to distal. The pulsatility index decreased significantly from location II to III and from I to II. However, the decrease was more pronounced along the Atlas slope than in the straight-vessel section below. The decrease of the resistance index was highly significant along the Atlas slope (location II to III). The decrease from location I to II was small and not significant. CONCLUSIONS: The pronounced decrease in pulsatility and resistance indices along the interindividually uniformly bent V3 segment compared with a straight segment of the vertebral artery indicates a physiologic attenuating effect of the Atlas slope on arterial flow pulsatility. A similar effect has been described for the carotid siphon. A physiologic reduction of pulsatility in brain-supplying arteries would be in accordance with several recent publications reporting a correlation of increased arterial flow pulsatility with leukoencephalopathy and lacunar stroke.

[Sexual and contraceptive behavior of teenagers and young adults. Selected results of the BZgA study "Youth Sexuality 2010"]. / Sexual- und Verhütungsverhalten Jugendlicher und junger Erwachsener. Ausgewählte Ergebnisse von Befragungen der Bundeszentrale für gesundheitliche Aufklärung (BZgA).

The BZgA study "Youth Sexuality 2010" clarifies the changes that have occurred in the sexual and contraceptive behavior of teenagers and young adults over the last 30 years. Among young Germans, there is now more gender similarity regarding both the age at which intercourse first takes place and contraceptive behavior. The proportion of German teenagers who take no contraceptive precautions when they have intercourse for the first time is now 8%, a lower figure than ever previously recorded. Communication about contraception, both at home and between the partners, is making a substantial contribution to responsible contraceptive behavior on the part of teenagers and young adults. Alongside education about sexuality in the family and at school, there are also structural influences on the positive developments witnessed in Germany. And yet there are still target groups that are inadequately reached. Many migrants are less well informed about bodily processes, their contraceptive practice is not as good, and their religious background tends to exclude them from access to information. Disabled teenagers and young adults constitute a target group about which to date we have insufficient knowledge. Education and social deprivation continue to be important factors in the differences seen in sexual and contraceptive behavior. In this area, proactive efforts are necessary.

Activity of pemetrexed against brain metastases in a patient with adenocarcinoma of the lung.

A 53-year-old woman was with adenocarcinoma of the lung metastatic to the brain was treated after several lines of chemotherapy with pemetrexed. After six cycles an impressive regression of the brain metastases was documented. A brief review of the literature on response of cerebral metastases to chemotherapy is added.

Low-dose bupivacaine with sufentanil prevents hypotension after spinal anesthesia for hip repair in elderly patients.

BACKGROUND: Hip fracture is common in the geriatric population. Patients in this group are often at high risk for perioperative complications from concurrent diseases. Conventional spinal anesthesia can be associated with hypotension but has a better postoperative outcome compared to general anesthesia. We judged that a reduced dose of bupivacaine in combination with sufentanil could give reliable blocks with minimal hypotension. METHODS: Fifty elderly patients were randomized into two groups. The study group received spinal anesthesia as a combination of hyperbaric bupivacaine 7.5 mg and sufentanil 5 microg while the control group received hyperbaric bupivacaine 15 mg. The hemodynamic stability of the patients and the quality of the blocks were compared. RESULTS: All patients had adequate duration of reliable blocks. More control group patients than study group patients required ephedrine due to hypotension. CONCLUSION: A reduced dose of hyperbaric bupivacaine (7.5 mg) in combination with sufentanil (5 microg) provides reliable spinal anesthesia for the repair of hip fracture in aged patients with few events of hypotension and little need for vasopressor support of blood pressure.