Cancer incidence in urban, rural, and densely populated districts close to core cities in Bavaria, Germany.

OBJECTIVE: An ecologic study on the level of districts was performed to evaluate the possible association between district type and risk of cancer in Bavaria, Southern Germany. METHODS: Cancer incidence data for the years 2003-2012 were obtained from the population-based cancer registry Bavaria according to sex and cancer site. Data on district type, socio-economic area deprivation, particulate matter exposure, tobacco consumption, and alcohol consumption were obtained from publicly available sources. The possible association between district type and cancer risk adjusted for age, socio-economic area deprivation, particulate matter exposure, tobacco consumption, and alcohol consumption was evaluated using multivariable multi-level negative binomial regression. RESULTS: We found a significantly reduced cancer risk in densely populated districts close to core cities and/or rural districts compared to core cities with respect to the cancer sites mouth and pharynx (women only), liver (both sexes), larynx (both sexes), lung (both sexes), melanoma of the skin (both sexes), mesothelioma (men only), connective and soft tissue (both sexes), corpus uteri, other urinary tract (men only), urinary bladder (both sexes), and non-Hodgkin lymphoma (both sexes). CONCLUSION: Our findings require further monitoring. Since the apparently increased cancer risk in core cities may be related to lifestyle factors, preventive measures against lifestyle-related cancer could be specifically targeted at populations in deprived core cities.

[A 67-year-old man with fever, night sweat and ascites]. / 67-jähriger Patient mit Fieber, Nachtschweiß und Aszites.

A 67-year-old man presented with fever, night sweat and abdominal complaints for about 4 weeks. Ultrasound and a computed tomography scan showed distinct ascites as the main finding, presenting as exsudate with predominating lymphoid cells. Because of long-term immunosuppressive therapy with the tumor necrosis factor (TNF)-α inhibitor golimumab for psoriasis, the suspicion for a possible tuberculous peritonitis arose. This was confirmed with an enzyme-linked immunospot assay, a high level of adenosine deaminase in the ascites and a peritoneum which was studded with multiple whitish nodules, corresponding to granulomas with giant cells. With a standard antituberculous regimen the symptoms were quickly relieved and finally complete restitution was achieved.

[Spindlecell soft tissue tumors of para- and retropharyngeal space: 5 patients, review of literature]. / Spindelzellige Weichgewebstumoren des Para- u. Retropharyngealraums: 5 Patienten, Literaturübersicht.

BACKGROUND: The parapharyngeal space (PPR) is poorly accessible to clinical investigation due to its complex anatomy. Neoplasms in this area are rare, become lately symptomatic and are diagnosed in advanced stages. Multiple entities can be differentiated though malignant mesenchymal tumors are uncommon. PATIENTS: We describe characteristic course of spindle cell soft tissue tumors in PPR based on 5 patients: 2 cases of synovial sarkoma (SyS), 2 cases of malignant peripheral nerve sheath tumor (MPNST) without neurofibromatosis, 1 case of Ektomesenchymoma (EM). RESULTS: Both patients with SyS showed under multimodal therapy with surgery, chemotherapy and radiotherapy a rapid tumor progression and early pulmonary metastatic disease. The 2 patients with MPNST were free of recurrence after tumor resection and in one case after adjuvant radiotherapy. The patient with EM showed no recurrence after surgery. CONCLUSION: Since malignant mesenchymal tumors of the PPR are unusual and also not have the typical behavior of metastatic epithelial neoplasms or malignant lymphoma, the diagnosis may be delayed. It is important to think in atypical lesions in PPR of the possibility of a soft tissue tumor and to arrange the necessary diagnostic steps. The imaging of choice of the PPR is the MRI, a staging adapted to the entity is necessary. The histological differentiation by immunohistochemistry and molecular genetics is complex, but is a vital to determine the optimal therapy. Diagnosis and treatment should take place in a specialized center.

Investigation of blood mRNA biomarkers for suicidality in an independent sample.

Changes in the blood expression levels of SAT1, PTEN, MAP3K3 and MARCKS genes have been reported as biomarkers of high versus low suicidality state (Le-Niculescu et al.). Here, we investigate these expression biomarkers in the Genome-Based Therapeutic Drugs for Depression (GENDEP) study, of patients with major depressive disorder on a 12-week antidepressant treatment. Blood gene expression levels were available at baseline and week 8 for patients who experienced suicidal ideation during the study (n=20) versus those who did not (n=37). The analysis is well powered to detect the effect sizes reported in the original paper. Within either group, there was no significant change in the expression of these four genes over the course of the study, despite increasing suicidal ideation or initiation of antidepressant treatment. Comparison of the groups showed that the gene expression did not differ between patients with or without treatment-related suicidality. This independent study does not support the validity of the proposed biomarkers.

[Potentially inappropriate medication in elderly primary care patients : A retrospective, longitudinal analysis]. / Potenziell inadäquate Medikamente bei älteren hausärztlich versorgten Patientinnen und Patienten : Eine retrospektive Längsschnittanalyse.

BACKGROUND: Elderly people are often burdened by several diseases. This accounts for a higher medication intake and increases the risk of adverse drug events. To minimize this risk, several lists (Beers, PRISCUS) have been published of drugs that elderly patients should not take. We present a longitudinal analysis of the use of potentially inappropriate medication (PIM) over a period 4.5 years in a cohort of patients aged 75 years or more. METHODS: Data were collected from the prospective, multicenter, observational study "German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe)," initially enrolling 3,327 patients. We investigated the prevalence of PIM by checking medications during visits to patients' homes. Furthermore, we analyzed the use of individual PIM agents over time. RESULTS: At baseline, we found a PIM prevalence of 29 % according to the PRISCUS list, which decreased to 25.0 % 4.5 years later (χ(2): 7.87, p = 0.004). The Beers list yielded a prevalence of 21 % at baseline, decreasing after 4.5 years to 17.1 % (χ(2): 10.77, p = 0.000). A time-dependent multilevel model confirmed these results. Older age, depression, and the use of numerous prescribed agents are independent risk factors for using a PRISCUS-PIM. CONCLUSION: Our results seem to support a trend toward a more rational drug therapy because fewer patients were prescribed PIM. Thus, for the individual patient, the risk of adverse effects and side effects is reduced as are the costs of these effects.

The impact of regional deprivation and individual socio-economic status on the prevalence of Type 2 diabetes in Germany. A pooled analysis of five population-based studies.

AIM: Our objective was to test the hypothesis that the prevalence of Type 2 diabetes increases with increasing regional deprivation even after controlling for individual socio-economic status. METHODS: We pooled cross-sectional data from five German population-based studies. The data set contained information on n = 11,688 study participants (men 50.1%) aged 45-74 years, of whom 1008 people had prevalent Type 2 diabetes (men 56.2%). Logistic multilevel regression was performed to estimate odds ratios (OR) and 95% confidence intervals (CI) for diabetes prevalence. We controlled for sex, age and lifestyle risk factors, individual socio-economic status and regional deprivation, based on a new small-area deprivation measure, the German Index of Multiple Deprivation. RESULTS: Adjusted for sex, age, body mass index (BMI), physical activity, smoking status and alcohol consumption, the prevalence of Type 2 diabetes showed a stepwise increase in risk with increasing area deprivation [OR 1.88 (95% CI 1.16-3.04) in quintile 4 and OR 2.14 (95% CI 1.29-3.55) in quintile 5 compared with the least deprived quintile 1], even after controlling for individual socio-economic status. Focusing on individual socio-economic status alone, the risk of having diabetes was significantly higher for low compared with medium or high educational level [OR 1.46 (95% CI 1.24-1.71)] and for the lowest compared with the highest income group [OR 1.53 (95% CI 1.18-1.99)]. CONCLUSION: Regional deprivation plays a significant part in the explanation of diabetes prevalence in Germany independently of individual socio-economic status. The results of the present study could help to target public health measures in deprived regions.

[Vestibular schwannoma. Part 2: therapy, prognosis, and rehabilitation]. / Vestibularisschwannom. Teil 2: Therapie, Prognose und Rehabilitation.

During the past few decades, therapeutic options in vestibular schwannoma have become more versatile. The former dominant surgical strategies are complemented by radiotherapeutic procedures and the so-called wait-and-scan option. Therefore, the decision to proceed has become more difficult and individual solutions should be found on an interdisciplinary basis. In particular, patients suffering from neurofibromatosis type 2 should be discussed in an experienced center. Furthermore, rehabilitation of auditory, vestibular, motoric, and neurologic functions requires extended experience in this complex disease.

[Vestibular schwannoma: Part I: epidemiology and diagnostics]. / Vestibularisschwannom : Teil I:Epidemiologie und Diagnostik.

Vestibular schwannoma is with 80% the most frequent of all tumors of the cerebellopontine angle. Usually, this benign, neuroectodermal, mostly unilateral occurring tumor is called acoustic neuroma, although it develops from the Schwann cells of the nerve sheath of the eighth cranial nerve. The tumor is localized in the meatus acusticus internus in the majority of cases. The most common initial symptom is a unilateral or, at least, asymmetric hearing loss. Other symptoms may include tinnitus and feeling of insecurity or vertigo, but adjacent cranial nerves may also be affected. Besides clinical and apparatus-based (neuro-)otological diagnostics, MRI imaging has established itself as the gold standard with a sensitivity and specificity of up to 100%.

Coronary computed tomography angiography indicates complexity of percutaneous coronary interventions.

BACKGROUND: Coronary computed tomography angiography (CCTA) provides information regarding lesion morphology and three-dimensional coronary anatomy incremental to coronary angiography. We addressed the question whether preprocedural CCTA bears potential for guiding percutaneous coronary interventions (PCI). METHODS AND RESULTS: Sixty-six coronary lesions attempted with PCI within 6 months of preprocedural CCTA were retrospectively assessed. Lesion parameters from unenhanced computed tomography (CT) for calcium scoring and CCTA were analyzed and compared with PCI complexity. Complex PCI was defined as use of buddy wire, kissing balloon, necessity of high pressure balloons, or rotablator. Complex PCIs were observed in 32 interventions (48%). Median Agatston score and Hounsfield units were higher in lesions with complex as compared to those with non-complex interventions with 130 (interquartile range, 23-276) vs 29 (0-158; P=.01), and 493 (245-631) vs 341 (68-520 Hounsfield Units; P=.04), respectively. Median local plaque volume and plaque mass were higher in complex PCI with 17 (2-39) vs 5 (0-19.5 mm³; P=.007), and 48 (15-99) vs. 16 (1.5-63 mg hydroxyapatite/mm³; P=.03), respectively. Lesions leading to complex PCI were longer [1.8 (1.2-2.8) vs 1.3 (0.8-1.7) cm; P=.03], and had a higher rate of calcified plaques (23% vs 3%; P=.03). There was a significant correlation between CCTA- and angiography-derived local SYNTAX Scores (P<.001); the CCTA-derived score seems to be predictive for failed and complex PCI (area under curve = 0.75 ± 0.13 and 0.66 ± 0.08, respectively). CONCLUSIONS: Preprocedural lesion assessment by CCTA indicates complexity of PCI. In patients with suspected complex coronary anatomy, prior CCTA adds important information for planning PCI.

[Chondrosarcoma of the larynx. Experience gained in Freiburg since 1999]. / Chondrosarkome des Larynx. Freiburger Erfahrungen seit 1999.

BACKGROUND: Chondrosarcomas are rare tumors of the head and neck. Nevertheless, they display the most common non-epithelial malignancy of the larynx. MATERIALS AND METHODS: Between 1999 and February 2010 we treated six patients with laryngeal chondrosarcoma. The group included two female and four male patients ranging in age from 54 to 82 years. RESULTS: An 82-year-old female patient died 3 months after diagnosis and tracheostomy due to other underlying diseases. An 82-year-old male patient underwent primary radiation therapy. In the other patients, we performed a modified hemilaryngektomy in three cases and a laryngectomy in one. In those four cases, there were no signs of recurrent disease 50, 85, 87 and 95 months after surgery, respectively. There were no local or distant metastases. CONCLUSIONS: Chondrosarcomas of the larynx are slow growing neoplasms. Metastases occur in less than 3% of cases. Complete resection is the therapy of choice. Function-preserving surgical approaches should be favoured.

[Therapy of posterior orbital tumors]. / Therapie posterior gelegener Orbitatumoren.

Tumors of the posterior orbit require different therapeutic modalities, depending on the histological entity. In the orbit all structures are in close relationship and the endocranium is in the direct proximity. This requires profound knowledge of topographic anatomy and high therapeutic precision. The surgical approach to the posterior orbit via a ventral intraorbital approach is strongly restricted due to the ocular bulb which consumes most space in the anterior orbit. Therefore if the bulb and vision are to be retained extraorbital surgical corridors are predominantly preferred. These are classified into extracranial and intracranial approaches. In detail, the former are medial transethmoidal orbitotomy, caudal transmaxillar orbitotomy and lateral orbitotomy. Frontolateral and frontotemporal orbitotomy as well as frontal, bifrontal and subfrontal orbitotomy are intracranial approaches. Apart from surgical methods there are several forms of radiotherapy which can be applied to orbital tumors under certain indications. Radiotherapy may be performed with external fractionated photon radiation or as stereotactic radiation, with heavy ions or protons or as brachytherapy. In this article various therapeutic interventions to the posterior orbit and the indications and potential side-effects are described.

[Therapy of tumors of the anterior orbit]. / Therapie anterior gelegener Orbitatumoren.

Tumors of the orbit are diagnosed on clinical and neuroradiological criteria. A biopsy may histologically confirm uncertain mass lesions. The patients' age and medical history predispose for certain tumor entities among the rather heterogenous spectrum of possible diagnoses. The therapy depends on the degree of malignancy and its location within the orbit. Among the different options, surgical excision is the most common followed by radiation therapy either in combination with surgery or alone. Chemotherapy plays a subsidiary role in certain lymphomas or metastases. This review covers the surgical techniques and treatment principles for tumors of the anterior orbit, explains radiotherapy techniques and briefly covers chemotherapy. Pediatric tumors of the orbit are covered separately.

[Insertion results for Contour™ and Contour Advance™ electrodes: are there individual learning curves?]. / Insertionsergebnisse von Contour™- und Contour-Advance™-Elektroden: Gibt es individuelle Lernkurven?

The aim of our study was to evaluate results of insertion following cochlear implantation with Contour™ and Contour Advance™ electrode arrays in adult patients and to analyze individual insertion results for three experienced surgeons. We performed a retrospective analysis of postoperative 3D volume tomography results in 223 adult patients. The intracochlear electrode position was evaluated to be in scala tympani, scala vestibuli or with a dislocation from one scala to the other. Surgical methods were analyzed and assigned to the different surgeons. We observed a significant increase for scala tympani insertions from initially 33% to 84% and a reduction in dislocations from scala tympani to scala vestibuli from 71% with the Contour™ electrode to 22% with the Contour Advance™ electrode. Results for the different surgeons varied individually with regard to scala tympani insertion rates and dislocation rates over time. 3D Volume tomography offers an important method for postoperative quality control following cochlear implant surgery. The intracochlear electrode position could be determined in all cases. We were able to identify individual learning curves for insertion results. Controlling the insertion quality serves as a feedback of surgical results and may be helpful for improving surgical quality and thus rehabilitation results.

[Value of different strategies in the treatment of vestibular schwannoma: therapeutic aspects and literature analysis]. / Wertigkeit unterschiedlicher Methoden zur Behandlung von Akustikusneurinomen: Differenzialtherapeutische Aspekte und Literaturauswertung.

Treatment strategies for vestibular schwannoma have been extended and become more differentiated. An analysis of the international literature with the help of a PubMed search shows that otological and neurosurgical procedures as well as radiation therapies do not only compete but also complement each other. Standardized protocols for the classification of hearing, facial nerve function and quality of life enable a better comparison of functional results. Recent publications discuss - in addition to the standard of preserving facial nerve function and hearing - aspects of vestibular function as well as quality of life, especially in long-term follow up. In addition to effective tumour control, major focus is put on minimizing morbidity. The choice of therapy in patients with neurofibromatosis 2 and recurrent tumours is particularly challenging. The complex topic requires a profound knowledge of differential therapeutic aspects from consulting and treating physicians. Therefore, the individual treatment recommendation should be given in a specialized center.

[Intraluminal surgical procedures for glottic enlargement in bilateral vocal fold paralysis in adduction]. / Intraluminäre Verfahren der Glottiserweiterung bei bilateraler Stimmlippenparese.

Bilateral vocal fold paralysis with paramedian position of the vocal chords can result from iatrogenic or traumatic nerve injuries, neurologic disorders and extralaryngeal malignancies and usually causes significant shortness of breath while the voice is only slightly affected. Only about 10% of the affected patients tolerate the narrowed airway caused by bilateral vocal fold paralysis in adduction, so most patients are candidates for a surgical intervention. Today, a range of intraluminal surgical procedures for enlargement of the glottis in bilateral vocal fold paralysis have been described which intend to avoid or supersede tracheostomy and which have replaced time-consuming external approaches to the glottis. This report provides an overview of the most important intraluminal surgical procedures for bilateral vocal fold paralysis in adduction and comments in detail on indications, surgical techniques, advantages and potential complications of the presented procedures for temporary or definitive enlargement of the glottis.

[Jugular vein thrombosis and Lemierre's syndrome--severe complications of oropharyngeal infections]. / Jugularvenenthrombose und Lemierre-Syndrom--schwerwiegende Komplikationen oropharyngealer Infekte.

BACKGROUND: Acute oral or pharyngeal infections usually heal under adequate therapy within a few days. Therefore severe regionary or systemic complications are not regularly seen. PATIENTS AND METHODS: We report on 3 patients in whom during or after apparent recovery from a pharyngeal or perioral infection a one-sided painful swelling of the neck associated with fever and leucocytosis developed. RESULTS: Color Doppler sonography (CDS) revealed unilateral thrombosis of the internal jugular vein (IJV) in all cases, whereupon we initiated high-dosed parenteral antibiotic therapy and therapeutic heparinisation. Furthermore, we drained detectable abscess formations. Nonetheless, in one patient fever attacks occurred postoperatively, accompanied by septic-embolic lung infiltrates, corresponding to Lemierre's syndrome. In all cases, we achieved clinical recovery and remission of infection. The course was significantly prolonged in the patient with pulmonary involvement and in this patient no reperfusion of the IJV was achieved. CONCLUSIONS: Even today serious complications may occur unexpectedly in presumed everyday oral or pharyngeal infections. CDS is a suitable procedure to disclose a jugular vein thrombosis (JVT) promptly and non-invasively. Parenteral antibiotic therapy for at least 10 days is usually the therapy of choice for JVT; additional full-heparinisation is controversially discussed in the professional literature. Septic pulmonary embolism following pharyngeal infection and JVT, as described by Lemierre, was associated with a high rate of mortality in the pre-antibiotic era, and even today may be fatal in spite of appropriate and maximal therapy.

[Exophytic tumor of the parotid gland]. / Exophytischer Parotistumor.

An 81-year-old male patient presented at our department with a large (diameter 10 cm), exophytic lesion in the right parotid region. Magnetic resonance imaging showed the tumor to derive from the lateral part of the parotid gland. We performed complete tumor resection with selective ipsilateral neck dissection. The facial nerve could be preserved. The postoperative course was uneventful. Histopathologic and immunohistochemical examinations revealed a malignant fibrous histiocytoma. We present the diagnostic and therapeutic options of this unusual malignancy of the parotid gland.