Cardiopulmonary and cerebrovascular acclimatization in children and adults at 3800 m.

Maturational differences exist in cardiopulmonary and cerebrovascular function at sea-level, but the impact of maturation on acclimatization responses to high altitude is unknown. Ten children (9.8 ± 2.5 years) and 10 adults (34.7 ± 7.1 years) were assessed at sea-level (BL), 3000 m and twice over 4 days at 3800 m (B1, B4). Measurements included minute ventilation ( V ̇ E ${\dot{V}}_{\rm{E}}$ ), end-tidal partial pressures of oxygen ( P ETO 2 ${P}_{{\rm{ETO}}_{\rm{2}}}$ ) and carbon dioxide, echocardiographic assessment of pulmonary artery systolic pressure (PASP) and stroke volume (SV) and ultrasound assessment of blood flow through the internal carotid and vertebral arteries was performed to calculate global cerebral blood flow (gCBF). At 3000 m, V ̇ E ${\dot{V}}_{\rm{E}}$ was increased from BL by 19.6 ± 19.1% (P = 0.031) in children, but not in adults (P = 0.835); SV was reduced in children (-11 ± 13%, P = 0.020) but not adults (P = 0.827), which was compensated for by a larger increase in heart rate in children (+26 beats min-1 vs. +13 beats min-1 , P = 0.019). Between B1 and B4, adults increased V ̇ E ${\dot{V}}_{\rm{E}}$ by 38.5 ± 34.7% (P = 0.006), while V ̇ E ${\dot{V}}_{\rm{E}}$ did not increase further in children. The rise in PASP was not different between groups; however, ∆PASP from BL was related to ∆ P ETO 2 ${P}_{{\rm{ETO}}_{\rm{2}}}$ in adults (R2  = 0.288, P = 0.022), but not children. At BL, gCBF was 43% higher in children than adults (P = 0.017), and this difference was maintained at high altitude, with a similar pattern and magnitude of change in gCBF between groups (P = 0.845). Despite V ̇ E ${\dot{V}}_{\rm{E}}$ increasing in children but not adults at a lower altitude, the pulmonary vascular and cerebrovascular responses to prolonged hypoxia are similar between children and adults. KEY POINTS: Children have different ventilatory and metabolic requirements from adults, which may present differently in the pulmonary and cerebral vasculature upon ascent to high altitude. Children (ages 7-14) and adults (ages 23-44) were brought from sea level to high altitude (3000 to 3800 m) and changes in ventilation, pulmonary artery systolic pressure (PASP) and cerebral blood flow (CBF) were assessed over 1 week. Significant increases in ventilation and decreases in left ventricle stroke volume were observed at a lower altitude in children than adults. PASP and CBF increased by a similar relative amount between children and adults at 3800 m. These results help us better understand age-related differences in compensatory responses to prolonged hypoxia in children, despite similar changes in pulmonary artery pressure and CBF between children and adults.

Adaptation to Occupational Exposure to Moderate Endotoxin Concentrations: A Study in Sewage Treatment Plants in Germany.

Acute or chronic inhalation of endotoxin may lead to changes of lung function and inflammatory markers in the airways. Adaptation to workplace exposure may be possible. In this study, we investigated the possible difference in inflammatory markers assessed in nasal lavage fluid (NALF) in chronical exposure compared to voluntary subjects exposed acutely to endotoxin. We sought to define the variability of inflammatory markers in NALF and the dose-related changes after moderate exposure in naïve subjects. Endotoxin exposure (4-1039 EU/m3) resulted from routine work during one shift in sewage treatment plants. Subjects were matched to pairs (8 workers escorted by 10 students). Inflammatory markers were investigated before, directly after, and 16 h after the shift end. Additional NALF samples were collected in students without any specific exposure after 3 days. In NALF, total cell count, and interleukin (IL)-8 and IL-1ß concentrations were significantly higher in workers than in students at all times pointing to workplace-related long-lasting exposure resulting in adaptation. However, concentration of inflammatory markers without specific exposure in students showed a great variability, covering the whole range of values recorded in the workers. The findings of this study make us to recommend a repeated assessment of inflammatory markers in healthy volunteers before the investigation of exposure-related changes and a sample size adequate for statistical analysis.

[What do General Practitioners and Dentists Report about their Cooperation? A Qualitative Exploration]. / Was berichten Hausärzte und Zahnärzte über ihre Zusammenarbeit? Ergebnisse aus einer qualitativen Exploration.

OBJECTIVE: Against the background of well-described associations between oral and general health, the cooperation between general practitioners (GPs) and dentists is crucial. Besides treatment, this includes prevention. Administrative referral between these two professions is not provided by statute. Thus, the study addresses the question: How do dentists and GPs integrate the associations between oral and systemic health in daily routine? METHODS: A total of 28 semi-structured interviews were conducted with GPs and dentists from 3 structurally different regions in the Federal State of Baden-Wurttemberg. Participants were visited in their office. The interviews were recorded, transcribed and analysed by 2 dentists and sociologists using Mayrings' qualitative content analysis. RESULTS: Associations between general and oral health are partially known to both practitioners. However, contact between them is limited. GPs send patients directly to dentists, without contacting them - mainly due to a desolate dental status, rarely due to therapy-resistant headache or facial pain. Dentists contact GPs to clarify mainly medication or anticoagulation medications taken by patients prior to invasive procedures. Preventive aspects play a minor part. Consultation essentially depends on acquaintanceship. CONCLUSION: Separation by statute determines the cooperation. Oral cavity in daily care is demarcated. Holistic patient care is hindered by a lack of knowledge and daily routines.

Addition of rituximab to CHOP-like chemotherapy in first line treatment of primary mediastinal B-cell lymphoma.

BACKGROUND: The addition of rituximab (R) to CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) -like therapy has improved survival in primary mediastinal B-cell lymphoma (PMBCL) patients. However, these results were obtained in young low risk patients and a reevaluation in an unselected patient cohort is warranted. METHODS: In this study, we analyzed 80 PMBCL patients treated with a CHOP-based regimen with and without rituximab. RESULTS: In the non-rituximab cohort 10-year progression free survival (PFS) was 67% and 10-year overall survival (OS) was 72% versus a PFS of 95% and a OS of 92% in the rituximab group, PFS P = 0.001, OS P = 0.023. A subgroup PFS analysis by international prognostic index (IPI) risk revealed that all risk groups benefit from addition of rituximab to induction chemotherapy. In addition, OS probability was higher in the group of non-low risk patients who were treated with rituximab compared to those patients who did not receive rituximab (P = 0.035). In multivariate analysis, only addition of rituximab to induction chemotherapy and reaching complete remission (CR) after first line therapy had a beneficial effect on both PFS and OS, whereas IPI, age, upfront high dose (HD) chemotherapy/autologous blood stem cell transplantation (ABSCT) and rituximab maintenance had no impact on survival. CONCLUSIONS: Our data demonstrate a survival benefit in unselected PMBCL patients treated with CHOP-like induction regimen and additional rituximab independently of the IPI risk score.

The potential of eHealth in otorhinolaryngology-head and neck surgery: patients' perspectives.

The use of modern information and communication technologies (ICT) in daily life has significantly increased during the last several years. These essential online technologies have also found their way into the healthcare system. The use of modern ICT for health reasons can be summarized by the term 'eHealth'. Despite the potential importance of eHealth in the field of otorhinolaryngology (ORL), there is little understanding of patients' attitudes towards the deeper integration of these technologies into intersectoral care. The aim of this study was to gain a better understanding of patients' attitudes towards the use of modern ICT for intersectoral communication and information transfer in the field of ORL. Therefore, a structured interview was developed by an interdisciplinary team of otorhinolaryngologists, public health researchers, and information technology (IT) specialists. Overall, 211 ORL patients were interviewed at the Department of Otorhinolaryngology-Head and Neck Surgery, Tuebingen University Hospital, Germany, and 203 of these patients completed the interview. This study revealed ORL patients' perspectives on the potential of eHealth, especially for appointment scheduling, appointment reminders, and intersectoral communication of personal medical information. Furthermore, this study provides evidence that data security and the impacts of eHealth on the physician-patient relationship and on treatment quality warrant special attention in future research.

Do we still need autopsy in times of modern multislice computed tomography?-Missed diagnoses in the emergency room.

INTRODUCTION: In spite of increasing quality of emergency room (ER) assessment in trauma patients and improved accuracy of modern multislice computed tomography (MSCT), the number of potentially missed diagnoses is still controversial. The aim of this study was to compare the initial findings of ER assessment and MSCT to the findings during autopsy in trauma patients not surviving the first 48 h after admission. We hypothesized that autopsy was more accurate than MSCT in diagnosing potentially fatal diagnoses. PATIENTS AND METHODS: Between January 2004 and September 2007, all trauma patients undergoing ER treatment in our institution who deceased within 48 h after admission were analyzed regarding diagnoses from initial ER assessment, including MSCT, and diagnoses from autopsy. Data were prospectively collected and retrospectively analyzed. Autopsy reports were compared to diagnoses of ER assessment and MSCT. Missed diagnoses (MD) and missed potentially fatal diagnoses (MPFD) were analyzed. RESULTS: Seventy-three patients with a mean age of 53.2 years were included into the study. Sixty-three percent were male. Autopsy revealed at least one missed diagnosis in 25% of the patients, with the thoracic area accounting for 67% of these. At least one MPFD was found in 4.1% of the patients, all of them being located in the thorax. Total numbers of MD and MPFD were significantly lower for the newer CT generation (64 MSCT, N = 11), compared to older one (4 MSCT, N = 26). CONCLUSIONS: As determined by autopsy, modern multislice computed tomography is an accurate method to diagnose injuries. However, 25% of all diagnoses, and 4.1% of potentially fatal diagnoses are still missed in trauma patients, who deceased within the first 48 h after admission. Therefore, autopsy seems to be necessary to determine potentially missed diagnoses for both academic and medicolegal reasons as well as for quality control.

A phase I trial of the trifunctional anti Her2 × anti CD3 antibody ertumaxomab in patients with advanced solid tumors.

BACKGROUND: Ertumaxomab (ertu) is a bispecific, trifunctional antibody targeting Her2/neu, CD3 and the Fcγ-receptors I, IIa, and III forming a tri-cell complex between tumor cell, T cell and accessory cells. METHODS: Patients (pts) with Her2/neu (1+/SISH positive, 2+ and 3+) expressing tumors progressing after standard therapy were treated to investigate safety, tolerability and preliminary efficacy. In this study, ertu was applied i.v. in 2 cycles following a predefined dose escalating scheme. Each cycle consisted of five ascending doses (10-500 µg) applied weekly within 28 days with a 21 day treatment-free interval. If 2 pts experienced a dose limiting toxicity (DLT) at a given dose level, the maximum tolerated dose (MTD) had been exceeded. RESULTS: Fourteen heavily pretreated pts (e.g. breast, rectal, gastric cancer) were enrolled in the four main cohorts. Three (21 %) pts had to be replaced. Two serious adverse events (SAE) with possible relation to the investigational drug were seen, both fully reversible. A DLT was not detected. Consequently, the MTD could not be determined. All adverse events (AE) were transient and completely reversible. Most frequent AEs were fatigue (14/14), pain (13/14), cephalgia (12/14), chills (11/14), nausea (8/14), fever (7/14), emesis (7/14) and diarrhea (5/14). Single doses up to 300 µg were well tolerated (total dose up to 800 µg per cycle). We observed one partial remission and two disease stabilizations after first treatment cycle. CONCLUSIONS: Single doses up to 300 µg could be safely administered in an escalating dose scheme. Immunological responses and clinical activity warrant further evaluation in patients with Her2 over expressing tumors. TRIAL REGISTRATION: EudraCT number: 2011-003201-14; ClinicalTrials.gov identifier: NCT01569412.

[Psychosomatic Consultation in the Workplace--Description and Modelling of a New Health-Related Service]. / Psychosomatische Sprechstunde im Betrieb--Gestaltungsformen des Angebots.

GOAL OF THE STUDY: In Germany, mental disorders have increasing importance for disability and early retirement. However, patients may have to wait several months before becoming an appointment with a psycho(somatic) therapist. Accordingly, several companies initiated a "psychosomatic consultation in the workplace" (PCIW). This concept has been explored. METHODS: Qualitative data analysis (expert interviews with stakeholders, focus group interviews with occupational health physicians; Mayring's content analysis) focussed on the question of how the concept of a PCIW can be tailored to meet the employees' needs. RESULTS: Concepts and implementation of PCIW differed with regard to the aspects dissemination of information about the consultation, gatekeeping, place of the consultation, and number of appointments with the psycho(somatic) therapist. The concepts of PCIW may be described as more or less "restrictive" or "liberal". The interviewees emphasised the need for PCIW and discussed the involvement of the occupational health physician within this approach. PCIW proved of value. Yet, the interviewees were ambivalent regarding the fact that companies offer and pay for treatment which should be provided within standard health care. CONCLUSION: Shaping company-based elements of standard health care should respect setting-specific needs and involve in-company stakeholders into the process.

The impact of allogeneic stem cell transplantation on the natural course of poor-risk chronic lymphocytic leukemia as defined by the EBMT consensus criteria: a retrospective donor versus no donor comparison.

BACKGROUND: In a single-center retrospective donor versus no-donor comparison, we investigated if allogeneic stem cell transplantation (alloSCT) can improve the dismal course of poor-risk chronic lymphocytic leukemia (CLL). PATIENTS AND METHODS: All patients with CLL who were referred for evaluation of alloSCT within a 7-year time frame and had a donor search indication according to the EBMT criteria or because of Richter's transformation were included. Patients for whom a matched donor could be found within 3 months (matches) were compared with patients without such a donor (controls). Primary end point was overall survival measured from the 3-month landmark after search initiation. RESULTS: Of 105 patients with donor search, 97 (matches 83; controls 14) were assessable at the 3-month landmark. Matches and controls were comparable for age, gender, time from diagnosis, number of previous regimens, and remission status. Disregarding if alloSCT was actually carried out or not, survival from the 3-month landmark was significantly better in matches versus controls [hazard ratio 0.38, 95% confidence interval (CI) 0.17-0.85; P = 0.014]. The survival benefit of matches remained significant on multivariate analysis. CONCLUSION: This study provides first comparative evidence that alloSCT may have the potential to improve the natural course of poor-risk CLL as defined by the EBMT criteria.

Excellent long-term survival of 170 patients with Waldenström's macroglobulinemia treated in private oncology practices and a university hospital.

The purpose of this study was to compare treatment and outcome of patients with Waldenström's macroglobulinemia (WM) in four private oncology practices (PP) and a university hospital (UH) in southwest Germany. We retrospectively reviewed the charts of all patients with WM of the last two decades of four PP in Mannheim, Heidelberg, Karlsruhe, and Speyer and the Department of Hematology of the University of Heidelberg. One hundred seventy patients could be identified, 74 from PP, 96 from the UH. Median age was 63.3 years. Patients from PP were older (median 65.3 vs. 62.5 years, p = 0.01). Only 54 % of patients from PP have received treatment during the observation time, as compared to 78.1 % of the UH (p < 0.001). In PP, 35 % of treated patients have received rituximab, as compared to 62.6 % of the patients of the UH (p < 0.001). Sixty percent of treated patients of PP have received bendamustine, as compared to only 8 % of the patients of the UH (p < 0.001). Time to first treatment was significantly shorter in patients from the UH compared to PP (median 13.7 vs. 52.9 months, p = 0.05). A trend towards a better overall survival was observed for patients treated with a rituximab-containing first-line regimen. The International Prognostic Scoring System for WM had significant prognostic value. Median overall survival was 25.0 years and did not differ between PP and UH. Despite different treatment strategies between PP and UH today overall survival of patients with WM is excellent, and better than previously reported.

DEHP and its active metabolites: leaching from different tubing types, impact on proinflammatory cytokines and adhesion molecule expression. Is there a subsumable context?

INTRODUCTION: Di(2-ethylhexyl)phthalate (DEHP) is suspected to be toxic for several reasons. During contact with a lipophilic medium, DEHP leaks from polyvinylchloride (PVC), but its influence on inflammatory reactions remains unknown. We examined specific DEHP leaching out of different tubing types, the possibly modulated liberation of proinflammatory cytokines and the induction of adhesion molecule expression in primary endothelial cells. MATERIALS AND METHODS: Blood samples were circulated in traditional PVC, nodioctyl phthalate (DOP) PVC and heparin-coated PVC tubing within a Chandler loop model. The blood was tested for the concentration of DEHP and its active metabolites as well as the liberation of the proinflammatory cytokines TNFα and IL1ß. Furthermore, we exposed human endothelial cells to circulated blood and analysed them for the expression of the adhesion molecules ICAM-1, VCAM-1 and E-selectin. RESULTS: In contrast to the other tubing, PVC tubing showed significantly elevated DEHP levels, but no alteration was observed concerning a potential up-regulation of the cytokines or activation of the endothelial adhesion molecule receptors. CONCLUSIONS: Our data conclude that there is no correlation between DEHP leaching and the inflammatory response after ECC support, but this study showed that even DEHP-free material is leaching DEHP and its toxic metabolites.

[(Inter)national and regional health goals in academic social-medical education conception for teaching medical students at the Eberhard Karls University Tuebingen]. / (Inter)nationale und regionale Gesundheitsziele in der sozialmedizinischen LehreLehrkonzeption für Medizinstudierende an der Eberhard Karls Universität Tübingen.

BACKGROUND: Social medicine deals with the specific interactions between medicine and society within a constantly changing social environment. The Institute of Occupational and Social Medicine, University Hospital Tuebingen, focuses on this relationship within the academic teaching of the Medical Faculty. Many of the issues thus directly affect the national health objectives and especially the health targets of the state of Baden-Württemberg, summarised in the Health Strategy Baden-Wuerttemberg. MATERIAL AND METHODS: In addition to the recommendations of the German Society for Social Medicine and Prevention (DGSMP) for the social medicine curriculum and the specific definition of the content by the Tuebingen medical faculty, national and regional health-care goals are also taken into account in the teaching conception. RESULTS: Classes are increasingly offered as training courses in small groups (seminars, group work with practical training), instead of classic lectures. These teaching methods allow the students to take part more actively in social medicine issues and to think and act within a comprehensive understanding of health management based on societal goals and the needs of a good health system. The concept is supported by the curriculum design element "log-book skills" of the Medical Faculty of Tuebingen. Feedback elements for teachers and students shape the further development of the concept. In dealing with real system data, practical experience on site and case vignettes, the students experience the links between societal influences, political objectives and medical action as well as the importance of accessibility of medical services for equity in health chances. CONCLUSIONS: The fact that advice and expertise play a crucial role in accessibility is a component to which too little attention is paid and calls for emphasis in the teaching concept. This teaching approach will deepen the understanding of the influence of psychosocial context factors and the conditions of the structural framework on the medical outcome. Furthermore there is a need for providing knowledge and special skills, which enable medical doctors to guide their patients optimally within the healthcare system and to make their contribution to a good system.

[Quality assurance in coding expertise of hospital cases in the German DRG system. Evaluation of inter-rater reliability in MDK expertise]. / Qualitätssicherung in der Kodierungsbegutachtung von Krankenhausfällen im G-DRG-System. Prüfung der Interrater-Reliabilität bei MDK-Gutachtern.

AIM: The purpose of this study was to evaluate differences in the D-DRG results of a hospital case by 2 independently coding MKD raters. Calculation of the 2-inter-rater reliability was performed by examination of the coding of individual hospital cases. The reasons for the non-agreement of the expert evaluations and suggestions to improve the process are discussed. METHODS: From the expert evaluation pool of the MDK-WL a random sample of 0.7% of the 57,375 expertises was taken. Distribution equality with the basic total was tested by the χ² test or, respectively, Fisher's exact test. For the total of 402 individual hospital cases, the G-DRG case sums of 2 experts of the MDK were determined independently and the results checked for each individual case for agreement or non-agreement. The corresponding confidence intervals with standard errors were analysed to test if certain major diagnosis categories (MDC) were statistically significantly more affected by differing expertise results than others. RESULTS: In 280 of the total 402 tested hospital cases, the 2 MDK raters independently reached the same G-DRG results; in 122 cases the G-DRG case sums determined by the 2 raters differed (agreement 70%; CI 65.2-74.1). Different DRG results between the 2 experts occurred regularly in the entire MDC spectrum. No MDC chapter in which significant differences between the 2 raters arose could be identified. CONCLUSION: The results of our study demonstrate an almost 70% agreement in the evaluation of hospital cost accounts by 2 independently operating MDK. This result leaves room for improvement. Optimisation potentials can be recognised on the basis of the results. Potential for improvement was established in combination with regular further training and the expansion of binding internal code recommendations as well as exchange of code-relevant information among experts in internal forums. The presented model is in principle suitable for cross-border examinations within the MDK system with the advantage that further trends could be uncovered by more variety and larger numbers of the randomly selected cases.

[Need for nursing care among infants of Turkish and non-Turkish origin. An analysis of registry data of the medical service of the statutory health insurance in Westphalia-Lippe, Germany, 2004-2008]. / Pflegebedürftigkeit bei türkischstämmigen und -nicht-türkischstämmigen Säuglingen. Eine Analyse der Pflegegutachten des MDK Westfalen-Lippe von 2004 bis 2008.

BACKGROUND AND AIM: Infants of mothers with an immigrant background experience poorer health outcomes than infants in Germany as a whole. The aim of this study was to investigate whether differences exist in diagnoses leading to long-term nursing care among infants of Turkish vs. non-Turkish background. METHODS: We analysed records of the medical service of the statutory health insurance of the region Westphalia-Lippe, 2004-2008. We used a name algorithm to identify cases with Turkish migrant background. RESULTS: There were 1 107 applications for long-term nursing care, 141 of which concerned infants of Turkish origin. "Inborn malformations, deformities and chromosomal abnormities" was more often the reason for application among non-Turkish infants, "Certain conditions which have their origin in the perinatal period" were twice as common among Turkish as compared to non-Turkish infants. CONCLUSIONS: Our results do not support the -assumption that mothers of Turkish origin more often apply for long-term nursing care due to malformations of their infant than other mothers.

[Off-label therapy from the perspective of the medical insurance service]. / Off-Label-Therapie aus der Perspektive des MDK.

The assessment of off-label medications is one of the most common reasons for assessment of drugs for individual patients in the German medical services. Tension is not uncommon because of great expectations of patients and doctors on the one hand and the requirements of the law on the other. They often do not match. Even if there is a medically justified off-label use the road to drug approval is principally via the authorities with tested efficacy and safety in order not to deprive the patient of the protection of the Pharmaceuticals Act. The jurisdiction has approved criteria for reimbursement by the statutory health insurance only in clearly defined exception and one requirement is that there are no alternative forms of treatment. For serious diseases this is based on the evidence of drug approval; however, for immediately life-threatening situations a very low evidence level is sufficient.

[A new working shift model for anesthesiologists: an analysis 3 years after implementation]. / Neues Dienstzeitenmodell für Ärzte in der Anästhesie : Eine Analyse 3 Jahre nach Implementierung.

OBJECTIVE: The aim of this study was to assess the efficacy, appropriateness and cost-effectiveness of a new working shift model for anesthesiologists complying with the European working time directive (EWTD) at the University Hospital of Tübingen (UKT), Germany 3 years after implementation BACKGROUND: Applying the standards of the EWTD is challenging for university hospitals as doctors must comply with the challenge of combining patient care, research and teaching. So far there have been no data available for German university hospitals on how these requirements can be met. As the department of anesthesiology is also a service-providing department it is essential not to increase staffing costs with a new shift model. METHODS: In 2007 a new working shift model for the department of anesthesiology was designed and introduced in 2008. Shift planning and documentation of working hours were implemented electronically. The calculated number of doctors to run this model was 87.6 full time equivalents (FTE). For 2009 and 2010 the compliance with the EWTD parameters was checked for 1) average weekly working time limit (AWWTL) and 2) compliance to the maximum daily working time limit of 10 h (10 h DWTL). Furthermore, staffing costs for doctors in 2010 were compared to 2007. To check for the time spent in patient care the period of anesthetic attendance (PAA) was chosen, i.e. the total time of patient contact by anesthesiology staff. Data were analyzed descriptively for AWWTL and for 10 h DWTL. FTE, staff costs and PAA were evaluated by one-way ANOVA. RESULTS: The new shift model allowed 84.4 % of all doctors to comply with the individual AWWT limits of 54 h and 48 h in 2009 (81/96) and 76.0 % in 2010 (79/104). In 2009 61.5 % of anesthesiologists voted for opt-out (59/96) and 53.8 % did so in 2010 (56/104). The 10 h DWTL was respected by 84.0 % in 2009 and by 85.9 % in 2010. The mean number of anesthesiologists rose significantly from 78.4 FTE in 2007 to 82.5 FTE in 2009 and 84.6 FTE in 2010 (p < 0.001 for 2010 vs. 2007, p = 0.004 for 2009 vs. 2007 and was not significant for 2010 vs. 2009). Staff costs per FTE increased from 7,524.79 /month to 7,800.66 /month and 7,966.11 /month in 2007, 2009 and 2010, respectively with the differences being non-significant. The PAA increased significantly from a mean of 6,124 h/month in 2007 to 6,581 h/month in 2009 and 6,872 h/month in 2010 (p < 0.001 for 2010 vs. 2007, whereas 2009 vs. 2007 and 2010 vs. 2009 were not significant). Thus, labour costs increased from 96.59 /h PAA in 2007 to 98.53 /h in both 2009 and 2010, the differences being not significant. CONCLUSIONS: The newly designed shift model allowed a fair compliance with the EWTD in respect to AWTL and 10 h DWTL, although the calculated number of doctors to run the shift model could not be met in 2009 and 2010. Violations of the 10 h DWT limits were stable in 2009 and 2010; however the number of doctors exceeding the AWWT limits appeared to increase. The compliance with opt-out decreased from 2009 to 2010 and a high proportion of AWWTL violations resulted from the group of non-opt-out voters. The staff costs per hour PAA after implementation of the new shift model did not differ significantly from the year before although staffing costs increased by 7.2 % between 2007 and 2010. Costs increased by 162,454 /year for all PAA hours in 2010. Further evaluation of staff satisfaction with the new shift models is needed and already under way.

Primary mediastinal B-cell lymphoma treated with CHOP-like chemotherapy with or without rituximab: results of the Mabthera International Trial Group study.

BACKGROUND: The aim of this subgroup analysis of the Mabthera International Trial Group study was to evaluate the impact of chemotherapy and rituximab in primary mediastinal B-cell lymphoma (PMBCL) in comparison to other diffuse large B-cell lymphoma (DLBCL). METHODS: Patients were randomly assigned to six cycles of CHOP-like regimens with or without rituximab. RESULTS: Of 824 patients enrolled, 87 had PMBCL and 627 other types of DLBCL. Rituximab increased the rates of complete remission (unconfirmed) in both PMBCL (from 54% to 80%, P = 0.015) and DLBCL (from 72% to 87%, P < 0.001). In PMBCL, rituximab virtually eliminated progressive disease (PD) (2.5% versus 24%, P < 0.001), whereas without rituximab, PD was more frequent in PMBCL than in DLBCL (24% versus 10%, P = 0.010). With a median observation time of 34 months, 3-year event-free survival (EFS) was improved by rituximab for PMBCL (78% versus 52%, P = 0.012) and for DLBCL (81% versus 61%, P < 0.001). Overall survival benefit was similar for DLBCL (93% versus 85%, P < 0.001) and PMBCL (89% versus 78%, P = 0.158). CONCLUSION: In young patients with PMBCL (age-adjusted International Prognostic Index 0-1), rituximab added to six cycles of CHOP-like chemotherapy increases response rate and EFS to the same extent as other DLBCL. The combination of rituximab with CHOP chemotherapy is an effective treatment in PMBCL with good prognosis features.

Carotid endarterectomy within seven days after the neurological index event is safe and effective in stroke prevention.

BACKGROUND: Timing of surgery remains a controversial subject with some concerns persisting that the benefit of early carotid endarterectomy (CEA) offsets the perioperative risks. We investigated the neurological outcome of patients with symptomatic internal carotid artery (ICA) stenosis after surgery in relation to the timing of treatment. METHODS: From January 2005 to June 2010, 468 patients (n = 349 male, 74.6%, median age 71 years) underwent CEA for symptomatic stenosis. Perioperative morbidity and mortality rates were assessed in the 30 days' follow-up. RESULTS: The median time interval between index event and CEA was 7 days; the overall stroke and death rate reached 3.4%. There was no difference in the 30 days' rate of stroke /death rate, depending on the timing of surgery (n = 5/241, 2.1% in patients treated within 1 week vs. n = 10/215, 4.7% in patients treated thereafter, p = 0.12). Patients with a postoperative neurological deterioration had more often an ischaemic infarction on preoperative cerebral computed tomography (CCT) compared with those without deterioration (n = 6/15, 40.0% vs. n = 39/441, 9.0%, p = 0.003). Logistic regression analysis showed that patients with preoperative infarction on CCT had the highest risk for postoperative neurological deterioration. CONCLUSION: An infarction on the preoperative CCT leads to an increased risk for a postoperative deterioration after CEA. Patients should be treated at an early point in time with bland CCTs.

Arthritis predicting factors in distal intraarticular radius fractures.

INTRODUCTION: Intra-articular malunion with step off and gap formation is claimed to be crucial for radiocarpal degeneration. In addition to well-defined intraarticular malunion, the shape of the distal radius is important for unaffected wrist function. In typical intra-articular fracture patterns with a dorsoulnar and palmar ulnar fragment, alterations of the shape of the articular surface, in a kind of a cavity, without obvious step off can be observed. The aim of the present study is to determine the residual articular deformity following intra-articular radius fractures and to analyze their impact on the final clinical and radiological outcome. MATERIALS AND METHODS: Eighty one patients with dorsally displaced distal intraarticular radius fractures were followed up for a mean period of 9 years. Surgical treatment of all patients included open reduction, plate fixation and corticocancellous bone grafting. Radiological measurements included palmar tilt, radial inclination and radial shortening as defined by ulnar variance, intra-articular Stepps and the measurement of the anteroposterior distance of the radial joint surface. Clinical assessment included active range of motion (ARM) of the wrist, pain according to a visual analogue scale (VAS), grip power, working ability, Disability of Arm, Shoulder and Hand Score (DASH Score). RESULTS: Articular malunion in the form of a cavity in the sagittal plane measured 4.8 mm, 1.3 mm more than on the non-injured side. Anteroposterior distance measured 20.6 mm, 2.1 mm more than on the non-injured side. Articular step-off and gap was noticed in 11 patients. At the final follow-up examination, there was a significant difference in articular cavity depth and the anteroposterior distance between arthritis stage I and II. Arthritis stage was associated with the range of motion (ROM) in the sagittal plane, but had no significant influence on the DASH, pain level, grip strength and ROM in the frontal plane. CONCLUSION: ORIF leads to predictable results in the restoration of length and form of the distal radius. Increasing the articular cavity depth should be avoided to prevent degenerative arthritis at the radiocarpal joint at long-term follow-up visits.

Evaluation of the PC-1 K121Q and G2906C variants as independent risk factors for ischaemic stroke.

UNLABELLED: Overexpression of plasma cell membrane glycoprotein-1 (PC-1) inhibits insulin receptor tyrosine kinase activity and thus favours insulin resistance and atherosclerotic vascular disease. Recent findings indicate that the minor variant K121Q in the PC-1 gene confers an increased risk for early myocardial infarction independent of other established risk factors. We hypothesized that genetic variants in PC-1 may also influence the risk for cerebrovascular disease. AIM: Therefore, we assessed the association of the PC-1 K121Q variant in the coding region and a polymorphism (G2906C) in the 3' untranslated region of the PC-1 gene with the risk of stroke. PATIENTS: We analyzed 1014 patients with a history of ischaemic stroke from the Vienna stroke registry and 1001 control individuals without vascular disease. RESULTS, CONCLUSION: Genotype frequencies of both genetic variants were similar in patients and controls in the total study population. By multivariate analysis, no interactions were observed between the PC-1 genotype and established vascular risk factors. However, the PC-1 2906C allele was significantly more frequent in patients who suffered from stroke before the age of 40 years. In these patients the risk for ischaemic stroke was increased four-fold.