Outcomes, Prognostic Factors and Salvage Treatment for Recurrent Chordoma After Pencil Beam Scanning Proton Therapy at the Paul Scherrer Institute.

AIMS: The outcome of chordoma patients with local or distant failure after proton therapy is not well established. We assessed the disease-specific (DSS) and overall survival of patients recurring after proton therapy and evaluated the prognostic factors affecting DSS. MATERIALS AND METHODS: A retrospective analysis was carried out of 71 recurring skull base (n = 36) and extracranial (n = 35) chordoma patients who received adjuvant proton therapy at initial presentation (n = 42; 59%) or after post-surgical recurrence (n = 29; 41%). The median proton therapy dose delivered was 74 GyRBE (range 62-76). The mean age was 55 ± 14.2 years and the male/female ratio was about one. RESULTS: The median time to first failure after proton therapy was 30.8 months (range 3-152). Most patients (n = 59; 83%) presented with locoregional failure only. There were only 12 (17%) distant failures, either with (n = 5) or without (n = 7) synchronous local failure. Eight patients (11%) received no salvage therapy for their treatment failure after proton therapy. Salvage treatments after proton therapy failure included surgery, systemic therapy and additional radiotherapy in 45 (63%), 20 (28%) and eight (11%) patients, respectively. Fifty-three patients (75%) died, most often from disease progression (47 of 53 patients; 89%). The median DSS and overall survival after failure was 3.9 (95% confidence interval 3.1-5.1) and 3.4 (95% confidence interval 2.5-4.4) years, respectively. On multivariate analysis, extracranial location and late failure (≥31 months after proton therapy) were independent favourable prognostic factors for DSS. CONCLUSION: The survival of chordoma patients after a treatment failure following proton therapy is poor, particularly for patients who relapse early or recur in the skull base. Although salvage treatment is administered to most patients with uncontrolled disease, they will ultimately die as a result of disease progression in most cases.

Extent and determinants of hospitalization in a cohort of older disabled people.

OBJECTIVES: The purpose of this prospective cohort study was to determine the extent and determinants of hospitalization in a population sample of older disabled people. DESIGN: A longitudinal cohort study. SETTING: Noninstitutionalized disabled people in the region of Augsburg, South Germany. PARTICIPANTS: The study population included 2427 persons, aged 60 years and older, who, between 1991 and 1993, applied for benefits from the statutory health insurance system provided to the most severely handicapped noninstitutionalized persons. MEASUREMENTS: Baseline variables were derived from a standardized medical examination. Information about hospitalization and mortality until June 30, 1996, was extracted from records of the pertinent health insurance plan. Rate ratios (RRs) of hospitalization were derived from a multivariable Poisson regression model corrected for the correlation of multiple hospitalizations for each person. RESULTS: The overall absolute hospitalization rate was 6.7 hospitalizations per 10 person-years at risk, with a mean length of stay per hospitalization of 19.2 days. Multivariable analysis showed an inverse association of age and hospitalization. Persons cared for primarily by their children had a lower rate of hospitalization (RR = 0.83) than persons relying mainly on professional home care. Medical causes of disability and dependency with respect to activities of daily living were unrelated to the hospitalization rate. A total of 1415 persons (58.3%) died during follow-up. The rate of hospitalization was twice as high among these subjects compared with others. The hospitalization rate increased rapidly during the last year of life, with a peak increase in the last 3 months. CONCLUSIONS: This study expands the current inadequate database on hospitalization in Europe. Further expansion is necessary for the efficient allocation of medical resources to older people, a group steadily increasing in numbers.

Analytic strategies for recurrent events in epidemiologic studies: background and application to hospitalization risk in the elderly.

Due to the intraindividual dependence, specific analytic strategies are needed to assess risk factors for recurrent events. Although well established in the biostatistics literature, applications of these techniques are almost nonexistent in the field of epidemiology. The authors applied four different regression approaches for recurrent events (logistic, Poisson, and two different Cox proportional hazards regressions) to derive rate ratios of hospitalizations for various prognostic factors in a cohort of 2424 frail elderly. Over a median follow-up of 670 days, 3299 hospitalizations were observed in 1564 persons. Estimated rate ratios were similar in all four approaches and virtually identical in three. With all methods, confidence intervals of the rate ratios were considerably wider than with naive Poisson regression neglecting intraindividual dependence of events. Appropriate analysis of recurrent events is feasible with minor modifications of multivariable models familiar to epidemiologists and should no longer be neglected in epidemiologic research. In our setting, Poisson regression was the most convenient approach.

Alcohol consumption and Helicobacter pylori infection: results from the German National Health and Nutrition Survey.

Alcohol has strong antimicrobial activity and stimulates gastric acid secretion. Alcohol consumption may therefore compromise the living conditions of Helicobacter pylori in the stomach. We assessed the relation of alcohol consumption with H. pylori infection among 1,785 participants ages 18-88 in the German National Health and Nutrition Survey. Detailed information on dietary and lifestyle habits was obtained in personal interviews using a standardized food frequency questionnaire. Serum samples were analyzed for H. pylori immunoglobulin G antibodies by enzyme-linked immunosorbent assay. Overall prevalence of H. pylori infection was 39.2%. There was a clear inverse dose-response-relation between reported alcohol consumption and H. pylori infection. The relation persisted after control for potential confounding factors. The adjusted prevalence ratios (95% confidence intervals) for H. pylori infection among persons who consumed up to 10, 10 to 20, and more than 20 gm of alcohol per day compared with non-drinkers were 0.93 (0.77-1.13), 0.82 (0.65-1.04), and 0.71 (0.55-0.92). The inverse relation between alcohol consumption and H. pylori infection was even stronger when individuals with an indication of a recent change of alcohol consumption were excluded from the analysis. These findings support the hypothesis that moderate alcohol consumption may facilitate spontaneous elimination of H. pylori infection among adults.

[Reliability of expert assessment in disability evaluation within the scope of disability insurance]. / Reliabilitätsstudie zum Begutachtungsverfahren der Pflegebedürftigkeit im Rahmen der Pflegeversicherung.

With the introduction of the law on the statutory nursing care insurance in Germany ("Pflegeversicherung") in 1995, new benefits are provided for the most severely disabled people. Provision of benefits is contingent on a standardised examination performed by the medical service of the German statutory health insurance system (MDK). Results of the first study on the inter-rater reliability of this standardised examination are presented in this paper. The study population consisted of 218 elderly people (age range 60-99) living in 4 nursing homes in Munich. They were assessed by 2 senior medical students and 2 nurses using the standardised questionnaire of the MDK. Inter-rater reliability was assessed by means of kappa coefficients. Reliability was assessed with regard to the summary judgement of disability and the rating of single items (with regard to limitations in activities of daily living, mental status or the prognosis). Inter rater reliability was higher for the overall assessment of disability (kappa = 0.71 between medical students, kappa = 0.66 between nurses) than for most of the single items of the questionnaire such as "need of assistance with dressing" (kappa = 0.57 between medical students, kappa = 0.66 between nurses) or "ability to move" (kappa = 0.58 between medical students, kappa = 0.67 between nurses). Kappa-coefficients were particularly low for variables concerning prognosis of participants and for the mental status item "self-disorientation" (kappa = 0.19 between medical students, kappa = 0.23 between nurses). These patterns were consistently observed for the 2 rater groups (student-student, nurse-nurse). Between the 2 rater groups there was no substantial difference in reliability. However, there was a trend for higher agreement within the group of nurses. Although the overall reliability of the assessment of disability is relatively high in comparison to many other diagnostic procedures (such as x-ray readings), efforts should be made towards further improvement of this standardised examination.

[Empirical analysis of expert social medicine assessment of disability based on the decision of the Federal social court]. / Empirische Analysen zur sozialmedizinischen Begutachtung von Pflegebedürftigkeit vor dem Hintergrund eines Urteils des Bundessozialgerichts.

Objective assessment of need for nursing care should be based on well defined criteria. In 1993, the Federal German Social Court ("Bundessozialgericht", BSG) has given criteria for identifying individuals in permanent need of very intensive nursing care ("Schwerpfledgebedürftige"), who qualified for benefits granted by the Germany statutory health insurance system at that time. The criteria were primarily based on the number of activities of daily living for which the applicants were in need of help. The criteria were largely, but not entirely, consistent with previously established criteria employed by the Medical Service of the Health Insurances ("Medizinischer Dienst der Krankenversicherung", MDK), who was responsible for the assessment. An analysis of 4185 examinations carried out by MDK in the region of Augsburg in 1991-1993 showed that the majority of judgments were in agreement with the criteria given by BSG. However, individuals with psychiatric disorders or symptoms were often rated by MDK as being in permanent need of very intensive nursing care even if BSG criteria were not fulfilled. Exclusive judgement of nursing dependency on the basis of single activities of daily living appears to be inadequate for this group of persons.

[Requirements and provision of services for severely handicapped patients according to SGBV regulations 1991-1993]. / Beantragung und Gewährung von Leistungen für Schwerpflegebedürftige nach SGBV im Zeitraum 1991-1993.

Benefits for non-institutionalised severely disabled persons by the German statutory health insurance system were introduced in 1989 and extended in 1991. They were provided depending upon a standardised medical examination. We analysed 4185 examinations carried out in the city and the region of Augsburg in Southern Germany during 1991-1993 with regard to social and medical conditions of applicants. A total of 2706 persons examined (64.7%) were considered to meet the criteria of permanent dependence on nursing. The majority of applicants were more than 75 years of age (56.9%) even though all age groups were represented. The leading cause for dependence on nursing were diseases of the circulatory system (29.4%), followed by diseases of the nervous system (20.5%) and musculoskeletal disorders (14.6%). The main burden of nursing care was borne by the relatives; professional institutions played only a minor role. The degree of dependence with regard to basic activities of daily living, especially "turning in bed", "dressing" and "using toilet" showed the strongest association with the overall assessment of nursing dependence. With the introduction of a new nursing care insurance system in Germany ("Pflegeversicherung") in January 1995, benefits for disabled persons have been extended further. To improve prevention of nursing-care dependence and to ensure the best possible care of patients in need of such care, further investigations are required which should focus on risk factors for both nursing-care dependence and long-term nursing home and hospital admission of disabled persons.

Dependence of weighted kappa coefficients on the number of categories.

Weighted kappa coefficients are commonly used to quantify inter- or intra-rater reliability or test-retest reliability of ordinal ratings in clinical and epidemiologic applications. In this paper, we assess the dependence of weighted kappa coefficients on the number of categories and the type of weighting scheme, which vary between applications. The most commonly used weights are weights that are proportional to the deviation of individual ratings ("linear weights") or to the square of the deviation of individual ratings ("quadratic weights"). Quadratically weighted kappa coefficients are equivalent to the intraclass correlation coefficient and to the product-moment correlation coefficient under certain conditions. We illustrate that an increase of quadratically weighted kappa coefficients with the number of categories is expected under a broad variety of conditions, whereas linearly weighted kappa coefficients appear to be less sensitive to the number of categories. Number of categories and type of weighting scheme therefore require careful consideration in the interpretation of weighted kappa coefficients.

[Interrater reliability of instruments for the evaluation of needs of bedridden persons: a review of the international literature]. / Inter-Rater-Reliabilität von Instrumenten zur Beurteilung der Pflegebedürftigkeit: Ein Review der internationalen Literatur.

Objective and reliable rating of disability and functional dependence is of utmost importance for both medical and rehabilitation research and the practice of social medicine. The present paper provides an overview on internationally used disability scales and on studies that were carried out to determine their inter-rater reliability. Most of the scales were developed in the United States. The number and quality of inter-rater reliability studies strongly vary for various scales. In general, reliability was found to be high for summary scores of disability, whereas reliability strongly varied from extremely poor to excellent for single items of disability. This variation provides valuable suggestions for improving rating of disability.

[Interrater reliability of expert assessment by the health insurance medical service in determining eligibility for disability benefits]. / Untersuchungen zur Inter-Rater-Reliabilität des Begutachtungsverfahrens des Medizinischen Dienstes der Krankenversicherung (MDK) zum Vorliegen von Schwerpflegebedürftigkeit.

In this paper, we present the first study on the inter-rater reliability of a standardised examination of functional disability, employed by the medical service of the German statutory health insurance system ("Medizinischer Dienst der Krankenversicherung", MDK). 215 elderly adults (mean age 84) living in 6 nursing homes in Munich were included in the study. They were assessed by three medical students and two nurses of the respective nursing homes using the standardised questionnaire of the MDK. Inter-rater reliability of both a summary judgement of disability and of single items, such as impairments in activities of daily living, was assessed by kappa-coefficients. Inter-rater reliability was higher for the overall assessment of disability (kappa = 0.82 between nurses, kappa = 0.57 between medical students) than for most single items. Reliability was particularly low for some items on mental status (such as "restlessness") or perceptions (particularly visual perception) which require clearer definition. This pattern was consistently observed for the two types of comparisons (inter-students, nurse-nurse) and for different subgroups of the study population.

A systematic survey of breast cancer incidence in the Département of Rhône, France.

A systematic survey of all centres of diagnosis and care of breast cancer patients in the Rhône "département" of France was carried out to evaluate, for the year 1985, the incidence rate of breast cancer in an urban, industrialised part of France not covered by a cancer registry. Two hundred and fifty seven institutions or individuals were involved, covering the public and private sectors in the Rhône département, but also in neighbouring cities and elsewhere in France, which also enabled a search to be carried out for cases diagnosed or treated outside the département. Altogether, over this 1-year period, 801 new cases were identified (791 women and 10 men). This study demonstrated a high incidence of female breast cancer (80.5 new cases per 100,000 woman-years, standardised to the world population) which was particularly marked among women aged 40-60. This incidence is higher than that described by the cancer registry of the neighbouring département of Isère, but is close to the incidence found in Geneva. Results also concur with the relatively high mortality rate from breast cancer observed in the Rhône département.