[Early detection of cancer in the German National Cancer Plan: health policy and legal regulations]. / Krebsfrüherkennung im Nationalen Krebsplan : Gesundheitspolitischer Rahmen und gesetzliche Neuregelungen.

The "Law on the Further Development of the Early Detection of Cancer and Quality Assurance Through Clinical Cancer Registries" implements key recommendations of the German National Cancer Plan. The central objectives of the law are to improve the access, effectiveness, and quality of the existing cancer screening programs. It creates the necessary legal framework to turn the current opportunistic cervical cancer screening and colorectal cancer screening into population-based quality assured programs in accordance with the European guidelines for quality assurance in cancer screening. Each person in the eligible target population will receive a personal invitation letter with a view to increase the take-up rate of the screening program. Furthermore, there will be comprehensive quality assurance measures and evaluation activities. The law also stipulates that cancer registry data must be used for quality assurance purposes and the monitoring of the cancer screening programs. Special emphasis is put on the provision of balanced and unbiased information on the potential benefits and harms of the screening program. This is to ensure that the decision for or against participating in a screening program is based on an informed choice. Thus, German health policy is taking a clear stance against pushing take-up rates uncritically. This position is a paradigm shift of fundamental importance. The Federal Joint Committee - the highest decision-making body of the so-called joint self-government of physicians, dentists, hospitals, and statutory health insurance funds in Germany - is responsible for defining explicitly the details of the screening programs within 3 years.

Subject-specific musculoskeletal model of the lower limb in a lying and standing position.

Accurate estimation of joint loads implies using subject-specific musculoskeletal models. Moreover, as the lines of action of the muscles are dictated by the soft tissues, which are in turn influenced by gravitational forces, we developed a method to build subject-specific models of the lower limb in a functional standing position. Bones and skin envelope were obtained in a standing position, whereas muscles and a set of bony landmarks were obtained from conventional magnetic resonance images in a lying position. These muscles were merged with the subject-specific skeletal model using a nonlinear transformation, taking into account soft tissue movements and gravitational effects. Seven asymptomatic lower limbs were modelled using this method, and results showed realistic deformations. Comparing the subject-specific skeletal model to a scaled reference model rendered differences in terms of muscle length up to 4% and in terms of moment arm for adductor muscles up to 30%. These preliminary findings enlightened the importance of subject-specific modelling in a functional position.

["Water Hammer effect": a rare mechanism of hydrocephalus]. / Un mécanisme rare d'hydrocéphalie : l'effet coup de marteau.

We are reporting a case of functional hydrocephalus in a 66-year-old male patient presenting for gait disturbance. The etiology of the disease is a cerebrospinal fluid flow disturbance due to an ectatic basilar artery at the level of Monro foramen. Different pathophysiological mechanisms are discussed below.

Estimating foot inertial parameters: a new regression approach.

BACKGROUND: Estimating the inertial parameters for the foot (mass, center of mass position and inertia tensor) is important for applications involving the ankle joint such as inverse dynamics or stiffness measurement techniques (e.g. Quick-release). Scaling equations relying on foot length and body mass are widely used. However, because of the complex foot geometry, such equations may represent an oversimplified solution. Our aim was to evaluate these approaches and propose a new method. METHODS: Thirty-four right feet (17 Males, mean age and weight 30 years, 75 kg; 17 Females, 32 years, 61.5 kg) were reconstructed using a 3D surface scanner and used as geometrical references. Associated inertial parameters were calculated directly on each reference assuming a uniform density distribution and were compared to corresponding scaling and multiple regression estimates. Finally, an alternative method, based on multiple non-linear regressions, was proposed considering both foot length (L) and ankle width (W). FINDINGS: Comparisons showed that reference mass and moments of inertia were greater than scaling predictions with mean difference up to 33 and 16% for mass and moments of inertia respectively. The maximum standard errors of estimate for scaled moments of inertia reached 26%. The alternative solution involving ankle width in the equations lowered the gap with reference data (8.7% max standard errors of estimate) for both genders. INTERPRETATION: This strategy, requiring two simple and accessible measurements, may offer a better practicality/relevance compromise for clinical routine use, in regards to existing scaling and regression equations.

[Conservative laparoscopic treatment of diverticular peritonitis]. / Traitement laparoscopique conservateur des peritonites diverticulaires.

GOAL: To evaluate the results of a strategy of conservative laparoscopic treatment of peritonitis due to perforated diverticulitis for all patients, without exception for intraoperative findings or general patient condition, and to study the feasibility of eventual second-stage laparoscopic colectomy. MATERIALS AND METHODS: Between January 2003 and May 2007, 25 consecutive patients were urgently hospitalized with acute peritonitis due to perforated diverticulitis. All patients underwent laparoscopic peritoneal lavage and debridement; when there was a large perforation (ten cases), suture closure under laparoscopic control was performed. The Hinchey classification of peritonitis was Stage I in 2, Stage IIB in 8, Stage III in 9, and Stage IV in 6. RESULTS: Postoperative morbidity occurred in 12% of cases. Mean operative time was 71 minutes. Conversion to open laparotomy was not required. Complications included residual abscess (drained percutaneously with CT guidance), urinary tract infection, and prolonged drainage via the drain tract. Mortality was zero. Mean hospital stay was 13.8 days. Sixteen patients (64%) subsequently underwent laparoscopic colectomy as a second stage procedure. CONCLUSION: Conservative laparoscopic treatment of acute peritonitis due to perforated diverticulitis is a reliable alternative to open laparotomy in many cases; eventual laparoscopic colectomy at a subsequent stage is possible in the majority of patients.

Surgical revascularization for chronic intestinal ischemia.

AIM: The aim of this study was to assess outcome after surgical revascularization for chronic intestinal ischemia (CII). METHODS: From 1980 until 2003, 34 patients underwent revascularization for CII. Records were reviewed for operative technique, perioperative mortality and long-term outcomes. CII was diagnosed on the basis of clinical, arteriographic and angio-magnetic resonance imaging (MRI) criteria. Revascularization patency was monitored by arteriography, color duplex ultrasound scanning (CDS), computed tomography (CT)-scanning or angio-MRI. RESULTS: The celiac artery (CA) was severely diseased in 26 cases and the superior mesenteric artery (SMA) in 30 cases. Four patients presented single-vessel, 15 patients two-vessel, and 15 three-vessel involvement. Revascularization was performed by either simple (N=15) or double (N=19) bypass grafting. In 2 patients bypass grafting was combined with reimplantation. One patient underwent reimplantation alone. Median follow-up was 45 months. The 30-day mortality rate was 3%; there were 22 late death (64%). Primary revascularization patency was 94% at 1 month and 79.4% at 4 years. Clinical success rates were 85% and 70% respectively at 1 month and at 4 years. CONCLUSION: To choose the most suitable intervention, the Authors distinguished isolated CII treatable by single SMA revascularization from the digestive arteritis affecting the supramesocolic level of the abdomen, which requires double CA and SMA revascularization.

Emergency major abdominal surgery in patients over 85 years of age.

The aim of this retrospective study was to evaluate the outcome and prognostic parameters of patients over 85 years of age undergoing major abdominal emergency surgery. The medical records of 45 consecutive patients aged over 85 years who underwent major abdominal emergency surgery between May 1999 and November 2001 were reviewed. The mean patient age was 88 years. Eight patients were American Society of Anesthesiologists (ASA) IV or V, 21 were ASA III, and 16 were ASA I or II. We performed 38 median and 7 right subcostal laparotomies. Perioperative mortality was 26.6% (3 times higher than that of the overall population at the same age). Perioperative complications occured in 29.5% of patients. Ten patients returned home after surgery, of whom 70% remained alive at the end of the study. Twenty-three left the hospital for a long-term care institution or post-acute care unit: of these 20% remained alive at the end of the study. Among ASA I or II patients, 43.7% remained alive at the end of the study, although 18.7% died within 1 month of the surgery. Among ASA III, IV, or V patients, only 17.2% remained alive at the end of the study, and 34.5% died within 1 month of the surgery. None of patients classified as ASA IV or V survived for more than 6 month after surgery. With an overall mortality rate of about 30%, and with the clear correlation between increased mortality and higher ASA scores, the place of palliative treatment must remain a major consideration for patients in this age group classified ASA III or higher. When surgery is performed, early return home, should be encouraged.

[Adenocarcinoma of the gastric stump]. / Adénocarcinome sur moignon gastrique.

Cancer of the gastric stump is a classical late complication of gastrectomy for benign lesion. This tumor is defined by various criteria, including a minimal delay of 5 years since the initial gastrectomy and the benignity of the initial lesion. Early diagnosis is difficult since suggestive clinical signs are usually associated with advanced tumors. Prognosis is globally bad and theoretically justifies routine endoscopic screening. For tumors which can be radically resected, completion gastrectomy with lymphadenectomy is indicated and allows a 40% 5-year survival. In other cases, palliative treatment remains a major concern.

[Hemorrhagic digestive metastases from testicular choriocarcinoma]. / Métastases digestives hémorragiques du choriocarcinome testiculaire.

The metastasis of testicular choriocarcinoma are often hemorrhagic, primarily of cerebral or pulmonary seat. The secondary digestive localizations are rare and of bad forecast when they bleed. The surgical operation by laparotomy allows the topographic diagnosis and the treatment, but was made responsible for hemorrhagic decompensation of other metastatic localizations engaging the vital forecast.

[Not Available]. / Qualitätsmanagement und Qualitätssicherung in Deutschland Übersicht auf der Grundlage des Gutachtens "Bedarfsgerechtigkeit und Wirtschaftlichkeit" des Sachverständigenrates für die Konzertierte Aktion im Gesundheitswesen 2000/2001 : Übersicht auf der Grundlage des Gutachtens "Bedarfsgerechtigkeit und Wirtschaftlichkeit" des Sachverständigenrates für die Konzertierte Aktion im Gesundheitswesen 2000/2001.

Methods of quality management and quality assurance aim at improving medical facilities, procedures and services to benefit patients and avoid potential harm. It is prudent to call these measures "secondary technologies" because they are used to optimize the so-called "primary technologies" used in medicine such as diagnosis, therapy, rehabilitation and counseling. However, in light of the considerable efforts and high costs associated with quality assurance measures, it is important that these measures be subject to critical review. Like all other procedures or technologies used in health care, quality assurance measures must be reviewed with respect to their effects and costs prior to and during implementation. The primary issue of such pre-evaluation and re-evaluation is to analyze whether the benefits justify the costs and then to define how quality assurance measures can be used to help improve the outcomes of health care services. Quality assurance measures must focus on health care priorities. They should be limited to common and serious health problems, the core services of the different health care providers and to high-risk interventions. Quality assurance must contribute primarily to the health of patients and protect them from avoidable harm. Quality management must be patient and outcome oriented and should uphold the ideal of the responsible and informed patient, whose dignity and autonomy must be respected. Above all, strengthening the position of health care users requires comprehensive, comprehensible and easily accessible information on the targets and outcomes of quality management. This is a basic requirement for setting up a quality-oriented information culture in the health care system and should be given high priority.

[Primary malignant melanoma of the esophagus]. / Le mélanome malin primitif de l'oesophage.

The primary malignant melanoma of the esophagus is a rare tumor. The study aim was to report two cases, one treated by esophagectomy without thoracotomy and the other one by Lewis-Santy type esophagectomy. Both patients had recurrence. One died at the 24th month with liver metastases. The other one who had a cervical invaded lymph node, treated by radio-chemotherapy, is actually in complete remission 9 years after the diagnosis.

[Vascular deficit is the major cause of fistula in esophageal surgery]. / Le déficit vasculaire est la cause majeure des fistules en chirurgie oesophagienne.

AIM OF THE STUDY: The aim of this retrospective study was to find a link between vascularization failure and fistula in esophageal surgery. The originality of this study was to be based on hyperselective arteriogaphy of the artery vascularizing the gastric plasty, showing all vascular network of the plasty. PATIENTS AND METHODS: Hyperselective arteriography was carried out in 14 patients operated for esophagus cancer with a gastric plasty replacement. All these patients had a postoperative leakage or a bad vascularization of the gastric plasty during the operation. RESULTS: The vascularization of the gastric plasty was organized from the gastro-epiploic artery by anastomotic transversal network, depending on the left gastro-epiploic artery and left gastric artery. For the 14 patients, a constant link between leakage and vascularization failure could be proved. CONCLUSION: Esophageal surgery is dependent on the vascular status of the patient. The type of gastric plasty with large or narrow tubulization does not interfere with the quality of vascularization at the top of the plasty due to the preservation of a corporeal low branch.

[Methodological standards of the evidence-based approach of clinical guidelines development in Germany. Consensus between the scientific community, self-governed bodies and practice]. / Methodische Standards der Entwicklung evidenz-basierter Leitlinien in Deutschland. Konsens zwischen Wissenschaft, Selbstverwaltung und Praxis.

The most appropriate method of clinical guidelines development has been the subject of controversial debates in Germany during the last few years. The German Guidelines Clearinghouse at the Society for Quality in Medicine (Cologne) provided a discussion forum where clinicians, methodologists, the Association of the Scientific Medical Societies, and the corporate self-governed bodies (the health insurances, physicians' associations, and the hospital associations) agreed on the most important methods of an evidence-based approach for guidelines development. It was generally agreed that rigorous methodological standards should be followed to ensure both the scientific quality and the consensus quality in the development or revision of clinical practice guidelines. The agreement draws on the following topics: Scientifically valid guidelines: (1) are based on a comprehensive and systematic review of the best available evidence, (2) derive the recommendations from the best available evidence, and (3) demonstrate explicitly how the recommendations are linked to the evidence. The quality of consensus is ensured through (1) the participation of all relevant stakeholders in the guideline panel and (2) the application of formal consensus development methods. This type of an "evidence-based consensus guideline" is assumed to possess the highest level of scientific and political legitimacy.

[Public opinion on active euthanasia. The results of a pilot project]. / Das öffentliche Meinungsbild zur aktiven Sterbehilfe. Ergebnisse eines Pilotprojekts.

BACKGROUND AND OBJECTIVE: Despite eager public interest there have been few significant studies about the views of the German population on active euthanasia. It was our purpose to investigate, before undertaking a representative enquiry about this controversial and ethically sensitive topic, to what extent public opinion and the underlying norms, values and preferences can be adequately obtained by standardized data collection. COHORT AND METHODS: An interdisciplinary project group established a standardized written form of enquiry for measuring public opinion about active euthanasia. The test was performed on an anonymized convenience [corrected] sample of 110 persons living in North Germany. The questionnaires consisted of ten hypothetical cases, 11 potentially relevant viewpoints on likely decisions and eight frequently expressed arguments used in the debate for and against euthanasia. RESULTS: The reply rate to the questionnaire was 89% (n = 98; 37 men and 59 women, average age 39.5 [21-81] years). Agreement with active euthanasia in the various case examples ranged, according to context, from 85 to 93%. Active euthanasia was accepted by a clear majority, if preconditions of a voluntary decision by a mentally sound person and incurable, terminal disease (cancer) are cumulatively fulfilled. Otherwise it was rejected by most respondents. To a clear majority, active euthanasia implied both the chance that suffering would be shortened, but also the danger of misuse. Among the persons questioned those with professional experience of euthanasia were clearly more sceptical about active euthanasia than those without such experience. CONCLUSIONS: The standardized written questionnaire made it possible to obtain a differentiated picture of public opinion on active euthanasia. However, these data represent only a moment in the dynamic process of a norm being established within a society and must on no account be used as legitimizing active euthanasia by plebiscite.

[Determining priorities in the development of medical guidelines. 1: Criteria, procedures and actors: a methodological review of international experiences]. / Prioritätensetzung bei der Entwicklung medizinischer Leitlinien. Teil 1: Kriterien, Verfahren und Akteure: eine methodische Bestandsaufnahme internationaler Erfahrungen.

Setting priorities for the development of clinical practice guidelines has--similar to other decision-making procedures in health care--as much a political as a scientific component. Prioritizing guidelines aims to allocate resources to those health problems likely to maximize medical, social and economic outcomes associated with the use of these guidelines. This is a review and critical appraisal of international initiatives of systematically setting priorities for the development of clinical practice guidelines. Priority-setting criteria, both quantitative and qualitative methods as well as participation by relevant stakeholders will be discussed. This review provides possible decision-makers with an information basis which may assist in the development of concepts for setting priorities in a given context.

[Methodological quality of clinical practice guidelines in Germany: results of a systemic assessment of guidelines presented on the Internet]. / Methodische Qualität ärztlicher Leitlinien in Deutschland. Ergebnisse einer systematischen Untersuchung deutscher Leitlinienberichte im Internet

Critics claim that most of the German clinical practice guidelines are of poor quality having produced by informal ad hoc methodologies without a rigorous approach. This paper reports on the systematic appraisal of 329 guidelines published online by the Association of the Scientific Medical Societies (AWMF) in Germany. The results of this study suggest that most of the guidelines presented in Internet do not meet internationally recognised criteria for quality. Proposals are offered how to enhance the methodological quality of future guidelines.

[Goals, possibilities and limits of quality evaluation of guidelines. A background report on the user manual of the "Methodological Quality of Guidelines" check list]. / Ziele, Möglichkeiten und Grenzen der Qualitätsbewertung von Leitlinien. Ein Hintergrundsbericht zum Nutzermanual der Checkliste "Methodische Qualität von Leitlinien".

Recently a German appraisal instrument for clinical guidelines was published that could be used by various parties in formal evaluation of guidelines. An user's guide to the appraisal instrument was designed that contains a detailed explanation for each question to ensure that the instrument is interpreted consistently. This paper describes the purposes, format and contents of the user's guide, and reviews the key factors influencing the validity of guidelines. Taking into account international experiences, the purposes, chances and methodological limitations of a prospective assessment of clinical practice guidelines are discussed.

[Checklist for methodological quality of guidelines. A contribution to quality promotion of medical guidelines]. / Die Checkliste zur methodischen Qualität von Leitlinien. Ein Beitrag zur Qualitätsförderung ärztlicher Leitlinien.

The society of physicians of Germany and the society of panel physicians laid down in the "assessment criteria for guidelines in medical care" what kind of demands the medical selfadministration makes on guidelines. This measure also had the goal to support and strengthen the efforts of the AWMF for guidelines of high value. On the basis of these assessment criteria, a tool was compiled for the systematic registration and documentation of quality criteria for good guidelines for the first time in areas of German language. This check list is guided by the structure and content of the "Criteria for Appraisal for National Guidelines" by the Scottish Intercollegiate Guidelines Network.