Financial difficulties in breast cancer survivors with and without migration background in Germany-results from the prospective multicentre cohort study BRENDA II.

PURPOSE: We aimed to explore the trajectory of financial difficulties among breast cancer survivors in the German health system and its association with migration background. METHODS: In a multicentre prospective study, breast cancer survivors were approached four times (before surgery, before and after adjuvant therapy, five years after surgery) and asked about their migration history and financial difficulties. Migrants were defined as born/resided outside Germany or having citizenship/nationality other than German. Financial difficulties were ascertained with the financial difficulties item of the European Organisation for Research and Treatment of Cancer Core Instrument (EORTC QLQ-C30) at each time-point (cut-off > 17). Financial difficulties were classified in trajectories: always (every time-point), never (no time-point), initial (first, not fourth), delayed (only fourth), and acquired (second and/or third, not first). A logistic regression was conducted with the trajectories of financial difficulties as outcome and migration background as exposure. Age, trends in partnership status, and educational level were considered as confounders. RESULTS: Of the 363 participants included, 49% reported financial difficulties at at least one time-point. Financial difficulties were reported always by 7% of the participants, initially by 5%, delayed by 10%, and acquired by 21%. Migrants were almost four times more likely to report delayed (odds ratio [OR] = 3.7; 95% confidence interval [CI] 1.3, 10.5) or acquired (OR = 3.6; 95% CI 1.6, 8.4) financial difficulties compared to non-migrant participants. CONCLUSION: Survivors with a migration background are more likely to suffer from financial difficulties, especially in later stages of the follow-up. A linguistically/culturally competent active enquiry about financial difficulties and information material regarding supporting services/insurances should be considered.

To which extent do breast cancer survivors feel well informed about disease and treatment 5 years after diagnosis?

OBJECTIVE: In this study, we investigated to which extent patients feel well informed about their disease and treatment, which areas they wish more or less information and which variables are associated with a need for information about the disease, medical tests and treatment. METHODS: In a German multi-centre prospective study, we enrolled 759 female breast cancer patients at the time of cancer diagnosis (baseline). Data on information were captured at 5 years after diagnosis with the European Organisation for Research and Treatment of Cancer (EORTC) Information Module (EORTC QLQ-INFO24). Good information predictors were analysed using linear regression models. RESULTS: There were 456 patients who participated at the 5-year follow-up. They reported to feel well informed about medical tests (mean score 78.5) and the disease itself (69.3) but relatively poorly about other services (44.3) and about different places of care (31.3). The survivors expressed a need for more information concerning: side effects and long-term consequences of therapy, more information in general, information about aftercare, prognosis, complementary medicine, disease and therapy. Patients with higher incomes were better informed about medical tests (ß 0.26, p 0.04) and worse informed with increasing levels of fear of treatment (ß - 0.11, p 0.02). Information about treatment was reported to be worse by survivors > 70 years old (ß -0.34, p 0.03) and by immigrants (ß -0.11, p 0.02). Survivors who had received additional written information felt better informed about disease, medical tests, treatment and other services (ß 0.19/0.19/0.20/0.25; each p < 0.01). CONCLUSION: Health care providers have to reconsider how and what kind of information they provide. Providing written information, in addition to oral information, may improve meeting those information needs.

Free thyroxine level in the high normal reference range prescribed for nonpregnant women may reduce the preterm delivery rate in multiparous.

Preterm birth is the most common reason for perinatal morbidity and mortality in the western world. It has been shown that in euthyreotic pregnant women with thyroid autoimmune antibodies, L-Thyroxine replacement reduces preterm delivery rate in singleton pregnancies. We investigated in a nonrandomized retrospective observational study whether L-Thyroxine replacement, maintaining maternal free thyroxine serum level in the high normal reference range prescribed for nonpregnant women also influences the rate of preterm delivery in women without thyroid autoimmune antibodies. As control group for preterm delivery rate, data from perinatal statistics of the State of Baden-Württemberg from 2006 were used. The preterm delivery rate in the study group was significantly reduced. The subgroup analysis shows no difference in primiparous but a decline in multiparous by approximately 61% with L-Thyroxine replacement. Maintaining free thyroxine serum level in the high normal reference range prescribed for nonpregnant women may reduce the preterm delivery rate.

[Intraobserver and interobserver reliability of introital ultrasound after tension-free vaginal tape (TVT) procedure]. / Reliabilität der Introitussonografie nach Einlage eines spannungsfreien Vaginalbands nach dem TVT-Verfahren.

PURPOSE: To date, the evaluation of TVT by ultrasound has not been standardized. The aim of this observational study was to evaluate the intraobserver and interobserver variability of introital ultrasound. MATERIALS AND METHODS: Follow-up was performed for 202 patients after TVT procedure. The tape was characterized by the position in relation to urethral length (%) and the distance to the hypoechoic center of the urethra (mm). Furthermore, we assessed the shape of the tape (straight, curved or folded). All evaluations were performed by two experienced examiners (A, B) at rest and during Valsalva maneuver. All sonograms were archived digitally without measurement results. After 6 to 12 months, the sonograms were re-evaluated by one investigator (A). Depending on the first investigator, the results were compared as intraobserver (A-A) or interobserver (B-A) agreement. The first results were blinded for the second measurement. Agreement concerning the distances was assessed using the intraclass correlation coefficient (ICC). The concordance of the descriptive evaluation of the shape of the tape was characterized by the kappa coefficient (KC). RESULTS: The tape was regularly identified as an echogenic structure dorsal to the urethra. The intraobserver reliability concerning the position of the tape in relation to urethral length showed good reproducibility (at rest ICC 0.90, Valsalva maneuver: ICC 0.96). For the distance between the tape and the urethra at rest (ICC 0.83), there was also good reproducibility, but not during Valsalva maneuver (ICC 0.74). The shape of the tape showed only moderate reproducibility with accordance of 81 % at rest (KC 0.68) and of 79 % during Valsalva maneuver (KC 0.6). The interobserver comparisons showed good concordance in measuring the POS at rest (ICC 0.93), and during Valsalva maneuver (ICC 0.89), and the DIS at rest (ICC 0.89), and during Valsalva maneuver (ICC 0.87). The congruence of the estimation of the shape was 71 % at rest (KC 0.44) and 72 % during Valsalva maneuver (KC 0.49). CONCLUSION: The characterization of the TVT in the sagittal view by introital ultrasound shows good reproducibility with respect to position and distance, but not shape.

Ultrasound assessment of tension-free vaginal tape (TVT).

PURPOSE: To date, no standardization for the visualization of tension-free vaginal tape (TVT) has been established in clinical practice. The aim of this prospective observational study was to evaluate the shape and position of the tape using ultrasound and to compare this data with clinical postoperative results. MATERIALS AND METHODS: In a three-year period, 296 patients with clinically and urodynamically proven stress urinary incontinence (SUI) were treated with TVT and received follow-up in our department. An additional 12 patients, who were initially treated in other hospitals and had postoperative problems, were included in this study. Depending on the outcome after 3 months, the patients were divided into groups with and without specific disorders. The TVT was evaluated by introital ultrasound. The position of the tape was established by its location in relation to the urethral length and the distance to the hypoechoic center of the urethra (HCU). RESULTS: A suitable TVT position was determined in patients without any postoperative disorders. The mean value for the TVT position at rest in relation to the urethral length was 61 %. The distance to the HCU was 4.6 ± 1.5 mm. In patients with persistent SUI, the tape was more often located under the inner (3 % vs. 0 %) or outer quarter (29 % vs. 13 %, p = 0.004). In patients with residual volume, the distance to the urethra was significantly lower (2.7 vs. 4.6, p < 0.001). CONCLUSION: TVT may be regularly investigated using ultrasound. In combination with the clinical outcome, it represents an important method of evaluating the tape and assists in the planning of a future therapeutic course of action in cases of postoperative problems.

[Gynecological aspects of pain in the lower abdomen]. / Gynäkologische Ursachen von Unterleibsschmerzen. Die wichtigsten Differenzialdiagnosen im Uberblick.

Lower abdominal pain in women may be a manifestation of disorders of various organ systems. In addition to surgical, urological, orthopedic, neurological, and psychogenic problems, gynecological causes have a major role to play. In the absence of other confirmed causes, women with acute or chronic lower-abdominal pain must therefore be submitted to a gynecological investigation. Important components of such an investigation are clinical gynecological examination and transvaginal ultrasonography. In women of childbearing age, a pregnancy test should always be performed. For both diagnostic and therapeutic purposes, laparoscopy is constantly gaining in importance.

Classification of asymptomatic adnexal masses by ultrasound, magnetic resonance imaging, and positron emission tomography.

OBJECTIVE: The purpose of this study was to determine the diagnostic accuracy of sonography versus magnetic resonance imaging (MRI) and positron emission tomography (PET) in the characterization of adnexal masses. METHODS: One hundred and one patients with asymptomatic adnexal masses, which were scheduled for laparoscopy, underwent preoperative transvaginal ultrasound, MRI, and 2-[(18)F]fluoro-2-deoxy-d-glucose PET. Two different sonomorphological scoring systems were used to distinguish malignant from benign lesions. In addition, transvaginal Doppler flow velocimetry was performed and the resistance index (RI) of ovarian blood vessels was calculated. RI values below 0.45 were considered to indicate malignancy. MRI was evaluated on the basis of signal intensity and morphologic features such as wall thickness, septations, fluid or solid components, and vascularity. PET imaging was used to determine 2-[(18)F]fluoro-2-deoxy-D-glucose uptake. Malignancy was suspected if radiotracer uptake equaled or exceeded that of the liver. Based on histologic findings, sensitivity, specificity, positive and negative predictive values, and accuracy were first calculated independently for each imaging technique. Finally, a second session resulted in a consensus diagnosis being made based on the findings of all three modalities. RESULTS: Sonographic evaluation of adnexal masses resulted in correct classification of 11 of 12 ovarian malignancies (sensitivity 92%) but with a specificity of only 60%. With MRI and PET, specificities improved to 84 and 80% respectively, but sensitivities decreased. When all imaging modalities were combined, sensitivity and specificity were 92 and 85%, respectively, and accuracy was 86%. CONCLUSION: Combination of ultrasound with MRI and PET may improve accuracy in differentiation of benign from malignant ovarian lesions. However, negative MRI or PET results do not rule out early-stage ovarian cancer or borderline malignancies.

[Laparoscopic intraoperative differential diagnosis of adnexal tumors. A pilot study of 20 premenopausal patients]. / Laparoskopische Sonographie zur intraoperativen Differenzialdiagnostik von Adnextumoren. Eine Pilotstudie an 20 prämenopausalen Patientinnen.

AIM: The purpose of the study was to determine the feasibility and potential clinical value of laparoscopic intraoperative sonography in the female genital tract. PATIENTS AND METHOD: Intraoperative ultrasound was performed in 20 consecutive premenopausal patients with adnexal masses during laparoscopy using a 7.5 MHz semiflexible transducer. RESULTS: Laparoscopic ultrasound of the female genital tract improves image resolution. Furthermore, this new method allows accurate localisation of early tubal pregnancy and may be helpful if laparoscopic evaluation of the inner genital tract is impaired by severe adhesions. In 7 out of 20 patients, the therapeutical procedure was clearly influenced by the laparoscopic ultrasound findings, resulting in a benefit for the patients in all seven cases. CONCLUSION: Intraoperative laparoscopic ultrasound may improve minimal invasive management of adnexal masses.

Long-term morbidity following axillary dissection in breast cancer patients--clinical assessment, significance for life quality and the impact of demographic, oncologic and therapeutic factors.

OBJECTIVE: This study describes in detail the surgery-related symptoms following axillary lymph node dissection in breast cancer patients and considers both their significance for long term quality of life and the impact of possible influencing factors. MATERIAL AND METHODS: Three hundred and ninety six patients were studied retrospectively using a self-report questionnaire and a clinical examination. The symptoms, numbness, pain, edema, arm strength and mobility were evaluated. The subjective assessment of the degree of symptom intensity was compared with objective measurements. The extent of surgery (number of resected nodes, level of dissection) as well as the influence of demographic, oncologic and adjuvant measures (age, time interval, number of involved nodes, chemotherapy) were evaluated. RESULTS: Shoulder-arm morbidity and fear of cancer recurrence were the most important long-term sources of distress following breast cancer surgery in our study population. Demographic, oncologic and therapeutic measures including the extent of surgery had no influence on long-term morbidity. The intensity of all evaluated symptoms was reported to be more severe in patients' subjective statements than in the results of clinical assessment. CONCLUSION: Shoulder-arm morbidity following axillary dissection is a frustrating polysymptomatic disease that seems to be relatively unaffected by therapeutic measures. The surgical trauma necessary for adequate tumor staging (removal of 10 lymph nodes) seems decisive for the postsurgery syndrome following axillary dissection. For node-positive patients complete axillary clearing may improve tumor control without worsening long-termmorbidity. New techniques, such as the sentinel-node-biopsy, that selects patients with negative axillary status while preserving the integrity of axillary structures, may improve the overall morbidity.

[Utero- and fetoplacental hemodynamic measurements with low dose aspirin]. / Utero- und fetoplazentare hämodynamische Messungen unter low-dose Aspirin.

A prospective randomized double-blind study of low-dose aspirin treatment (100 mg/d) was conducted on a population of 43 pregnant women at risk of pregnancy-induced hypertension, preeclampsia, intrauterine growth retardation. Doppler ultrasound blood flow measurements of the uterine arteries and the umbilical cord, at the fetal and placental end, were obtained on a two-weekly interval in between 18 to 40 weeks of gestation. During the course of pregnancy Doppler indices of both vessels decreased, whereas the absolute velocity of the uterine arteries increased. Perfusion of both vessels did not show any relevant differences in between the aspirin- and placebo-group. Both groups showed a similar median duration of gestation at time of delivery (278 d aspirin vs. 270 d placebo). Comparison of median birthweight (3152.5 g aspirin vs. 2900 g placebo) did not show any significant difference. There were no haemodynamic effects of low-dose aspirin on the utero- and fetoplacental circulation to be demonstrated.

[External fetal version from breech presentation to cephalic presentation: modifying factors, reliability and risks]. / Aussere Wendung aus Beckenendlage in Schädellage: Einflussfaktoren, Nutzen und Risiken.

External cephalic version (ECV) was performed in 524 single pregnancies. The version was successful in 38.4%. Success is mainly influenced by parity, quantity of amniotic fluid and maternal weight. An emergency cesarean section was necessary in 0.6% because of fetal bradycardia. Compared to controls the ECV was not associated with the increase of a premature rupture of membranes, complications with umbilical cord or transfer of the child to the paediatric department. Also there was no difference in the pH or Apgar-ranges. One fetal death was diagnosed 17 days after ECV, the reason therefore remained unclear. There are existing a few other reports with similar cases. We conclude that ECV is a appropriate trial to convert the fetus into cephalic presentation, but because of possible complications precautions must be taken, e.g. that means to carry out the trial under conditions which allow immediate cesarean section and a frequent follow up of the woman until delivery.

[Diabetes screening in pregnant patients with different risk factors. Benefits, therapeutic success, consequences]. / Diabetes-Screening bei Schwangeren mit unterschiedlichem Risiko. Nutzen, Therapieerfolg, Konsequenz.

600 ethnically heterogeneous patients with various risk factors from outpatient obstetric clinic of the UFK Ulm were screened for gestational diabetes. Incidence with the 100 g oGTT was 21%, with fasting levels having the lowest prognostic value, and one hour levels having the best. After the diagnosis of gestational diabetes was established patients were counselled and put on diet, 7% received insulin additionally. Weight gain was far more acceptable in those patients compared to the group of patients with normal metabolism. We observed no significant differences concerning fetal macrosomia, caesarean section-rates, newborn apgar and ph-values compared to normal pregnant women. We confirmed the known risk factors, personal history, familial disposition and maternal age. A screening based only on these criteria, however, would fail to detect 20% of patients with gestational diabetes. A general screening must be postulated.