Medical adherence in patients with systemic lupus erythematosus in Germany: predictors and reasons for non-adherence - a cross-sectional analysis of the LuLa-cohort.

Objective Adherence to medication has a major impact on treatment control and success especially in chronic diseases but often remains unrecognized. Besides clinical, socioeconomic, disease-related and treatment-related parameters, general and personal health beliefs, as well as perception of health, can affect adherence. Our aim was to investigate the adherence to lupus-specific medications in German lupus patients and to assess influencing factors including detrimental or beneficial effects of health perceptions and beliefs. Methods The Lupus Erythematosus (LE) Long-Term Study (LuLa-study) is a nationwide longitudinal study among German Caucasian patients with systemic lupus erythematosus who have been assessed annually using a self-reported questionnaire since 2001. In 2013, we included questions concerning medical adherence (Morisky Medication Adherence Scale; MMAS-4), beliefs about medication prescribed (BMQ), illness perception and about the patients' health locus of control (HLC). We present a cross-sectional analysis to assess predictors of adherence using a multivariable stepwise logistic regression. Results Five hundred and seventy-nine patients participated, 81 of whom did not take any lupus-specific medication and 40 of whom did not complete the MMAS-4 and were therefore omitted. Only 62.7% reported high adherence. Unintentional behaviour for low medical adherence exceeded the intentional behaviour by far. The use of azathioprine (OR: 1.85; 95% CI: 1.02-3.34), prednisone <7.5 mg (OR: 1.56; 95% CI: 0.97-2.49), a higher age (OR: 1.06; 95% CI: 1.03-1.08) and higher external HLC (OR: 1.15; 95% CI: 1.01-1.30) proved conducive for high adherence in our multivariable model. On the contrary, the general perception of medication being harmful or addictive (OR: 0.89; 95% CI: 0.82-0.97) was detrimental. Conclusion A low belief that one's own health is determined by healthcare providers (external HLC) and the belief of the harmfulness of medication were independent predictors of low adherence besides age and the choice of the medical agent. The recognition of these potential obstacles in physician-patient relationships is essential to ameliorate adherence. Provision of sufficient information and education might help to reach the best possible outcome.

Foveolar gastric metaplasia of the duodenum: a frequent, so far neglected type of duodenal polyp.

Foveolar gastric metaplasia of the duodenum (FGM) is considered as imperfect mucosal healing in the context of H. pylori gastritis and intake of NSAIDs or ASS.  Typical endoscopic findings are redness of the mucosa, erosion/ulcer and loss of mucosal folds. During diagnostic histological examinations we observed a frequent so far not described association of FGM with endoscopically observed duodenal polyps. The archives of two institutes of pathology with high gastroenterological workload (approximately 100 000 patients per year) were investigated for an association between "duodenal polyp" and "foveolar gastric metaplasia". In Institute 1, of 481 duodenal polyps 41 % were classified as FGM, 9 % as adenoma and 2 % as heterotopic gastric mucosa. In 48 % no histological correlate was present. In Institute 2, 217 cases of FGM were diagnosed. Of these, in 69 cases the endoscopic finding was "polyp" (32 %). In the other cases, the endoscopic findings were mucosal defect (18 %), redness/inflammation (16 %), suspicion for gastric heterotopia (5 %) and scar (3 %). In 26 % of cases no pathologic endoscopic finding was reported. Both groups of patients with FGM showed a similar distribution of age ranges (24 - 83 years and 16 - 88 years), median age (62 years and 61 years, respectively) and a dominance of male sex (both 1.5:1). In conclusion, foveolar gastric metaplasia is a frequent, so far neglected correlate of endoscopically detected duodenal polyps.

Value of ultrasound in preoperative local staging in early breast cancer.

PURPOSE: The purpose of this study was to determine the precision of breast ultrasound for the measurement of breast lesions compared to the histological measurement. A number of other dependent variables were also analyzed. MATERIAL AND METHODS: 460 patients with 445 malignant lesions were examined using breast ultrasound and the lesions were measured and compared to the histologically measured size. The data was further analyzed according to histology, tumor stage, age, grading and therapy. RESULTS: Metric comparison showed good correlation between sonography and the pathologically measured size of breast lesions, especially in tumor stage T 1 and T 2 and within ductal invasive carcinomas. Higher tumor stages lead to imprecise measurements and the histological type of lobular invasive carcinoma also results in imprecise measurements. Age and grading do not influence measurement precision. CONCLUSION: Breast ultrasound allows precise measurement of breast lesions especially at lower tumor stages. The higher the tumor stage, the more imprecise the measurement becomes. Multivariate analysis shows no cross impact between tumor stage and histological type with respect to the quality of measurement.

[Predicting response to therapy in breast cancer]. / Vorhersage des Therapieansprechens beim Mammakarzinom.

Molecular staging of breast cancer with microarray technologies leads to different gene expression profiles distinguishing 4 special groups: luminal A and B subtype, HER2 subtype and basal subtype. These 4 groups show a different prognosis as well as different behaviours and responses to adjuvant therapy. The development of gene expression profiles to classify breast cancer may contribute to the targeted institution of adjuvant therapies. Especially the 21-gene recurrence score (Oncotype DX) and the 70-gene profile (Mamma-print) have become intensively examined prognostic and predictive tools. As chemotherapy is an integral component of adjuvant therapy in early breast cancer but estrogen-receptor-positive breast cancer is the most common type, patient selection for adjuvant chemotherapy is of particular interest. In instances when the benefit from chemotherapy seems modest, there is a decision making tool beside traditional histopathological parameters that might provide additional objective prognostic and predictive information. Those genomic decision making approaches may yield more rational treatment choices and may keep patients from systemic treatment modalities of lower value.

[Pathophysiology of bone metastases in urologic carcinomas]. / Pathophysiologie der Skelettmetastasierung urologischer Karzinome.

The skeletal system is the most frequent metastatic site of hematogenous spread of urologic carcinomas. Osseus metastases are classified as osteoneutral, osteolytic, osteoblastic and combinations thereof. Osteolytic metastases lead to bone resorption by activating osteoclasts, while osteoblastic metastases stimulate osteoblasts by paracrine mechanisms. The local osteoblastic effect is associated with secondary systemic bone resorption. The use of bisphosphonates is now an established supportive therapy and newer treatment strategies including targeted intervention in the pathophysiology of bone metastases and radioimmunotherapy are being applied or will be coming soon.

[5th Report of the German Association of Cardiologists in Private Practice (BNK) on Quality Assurance in Cardiac Catheterization and Coronary Intervention 2003-2005]. / 5. Bericht des Bundesverbandes Niedergelassener Kardiologen zur Qualitätssicherung in der diagnostischen und therapeutischen Invasivkardiologie 2003-2005.

On behalf of the German Association of Cardiologists in Private Practice (BNK) the Steering Committee of the QuIK Registry reports on the results of the voluntary quality assurance in invasive cardiology in 2003-2005 and compares it to other data collections. In 2005 more than 70% of diagnostic (LHK) and 78% of therapeutic (PCI) cardiac catheterization procedures in private practice were entered into the registry. Altogether 229,462 LHK and 64,818 PCI were documented over the 3 years. In the reported period age of patients, percentage of acute coronary syndromes and three-vessel coronary artery disease increased in LHK as well as in PCI while consumption of contrast media and fluoroscopy time decreased. By implemented possibility of follow-up, a high rate of external auditing (monitoring) and certification QuIK remains a worldwide unique quality assurance project in cardiology. On a stable data basis over 10 years the QuIK Registry enables the implementation of quality indicators for future quality assurance purposes.

Long-term results of a three-week intensive cardiac out-patient rehabilitation program in motivated patients with low social status.

UNLABELLED: The short-term benefits of cardiac rehabilitation (CR) are well established. In contrast, well-documented long-term results are rare. The objective of this longitudinal multi-centre observational study was to examine the effects of intensive out-patient CR in a larger patient cohort, especially for patients with low social status. We present the final results 24 months after CR. METHODS: The study group of 327 patients (288 men, 39 women, aged 56.0+/-10.8 years, coronary artery disease in 295, other cardiac diseases in 32) participated in a 3- week CR programme followed by clinical re-evaluations 6 (III), 12 (IV) an 24 (V) months later. RESULTS: The improvement in mean maximal performance of 100.5+/-31.4 to 123.1+/-36.2 W (p<0.01) achieved during CR was further improved to 128.7+/-40.9 W (p < 0,01) after 24 months. Of the patients, 61.2% reported regular physical activity during the 24 months of the study. The lipid management achieved by CR was maintained over 24 month. At I 65%, at II 84.4% and at V 82.4% of the patients with coronary artery disease (CAD) were undergoing lipid lowering therapy. BMI increased from 26.8+/-3.0 to 27.6+/-3.6 kg/m2 (p < 0.01) during follow-up. Of the patients, 23.2% were active smokers at V. Cardiovascular diagnosis remained unaltered in 74.3% of patients. The obtained results are interesting with respect to the social status of the patients since 68% were general laborers. The results confirm the long-term effectiveness of an intensive 3-week out-patient CR programme. Most of the benefits achieved by CR appear to be sustainable in this population for at least 2 years.

[Surgical management of ovarian ectopic pregnancy]. / Operative Therapie der ovariellen Gravidität--Fallbericht und Ubersicht.

Ovarian pregnancies represent a small fraction of ectopic gestations. They are especially feared due to their life-threatening intraabdominal hemorrhage. Pre- and intraoperative diagnosis is difficult. Pathogenetically ovarian pregnancy arises from the retention of a fertilized ovum in the ovary. General guidelines for the medical management are missing. In this case report, we diagnosed a subacute ruptured ovarian pregnancy during surgery and performed a partial ovarectomy via operative laparoscopy. Other therapeutic options in managing ovarian ectopic pregnancy will be discussed.

[Prevention of arteriosclerosis. Importance of the treatment of arterial hypertension]. / Prävention der Atherosklerose. Stellenwert der Behandlung der arteriellen Hypertonie.

In most European countries and Northern America, cardiovascular diseases induced by atherosclerosis are the most common cause of death in older people. People surviving acute myocardial infarction or stroke suffer often by disabilities or handicaps. The lifelong care of such patients is expensive and plays a major role for increment of costs in public health systems. Prevention of atherosclerosis will reduce cardiovascular morbidity and mortality, enhance quality of life and prolong lifetime of patients. Therefore the worldwide accepted risk factors of atherosclerosis have to be treated consequently and early enough within the meaning of primary prevention. Hypertension is one of the six major cardiovascular risk factors and is defined as elevated blood pressure above 140/90 mmHg. In case of hypertension, diagnostic efforts has to be focussed on detection of additional cardiovascular risk factors, secondary forms of hypertension, end organ damage or associated diseases. All therapeutic strategies are based on life style changes, which cover weight reduction, sodium restriction, controlled alcohol consumption and increment in physical activity. Pharmacotherapy will be added in regard to the global risk of the patient and the success of the life style changes. Selection of antihypertensives and their optimal combination will be determined by associated diseases (compelling indication), side effects and individual response in blood pressure. Goal of treatment is the normalization of blood pressure below 140/90 mmHg independent of age or sex. In diabetics and in case of nephropathy the goal is set lower (below 130/80 mmHg).There is strong evidence that reduction in blood pressure is followed by a decrease in the incidence of myocardial infarction, stroke, heart failure, nephropathy, and even in cardiovascular mortality. The success of antihypertensive therapy is greater in high risk patients like older people, patients with isolated systolic hypertension or diabetics. Risk reduction correlates well with the degree in blood pressure reduction. However, to minimize cardiovascular risk in hypertensives all additional risk factors have to be treated too.

Ultrasound-guided large-core needle biopsies of breast lesions: analysis of 962 cases to determine the number of samples for reliable tumour classification.

The objective of this one-institutional study was to determine the number of large-core needle biopsies (LCNB), under three-dimensional ultrasound (3D-US) validation, that are sufficient to obtain a reliable histological diagnosis of a sonographically detectable breast lesion. Over an 28-month period, 962 sonographically guided LCNB were performed under 3D-US validation to assess 962 breast lesions. All biopsies were carried out with an automated core biopsy device fitted with 14-gauge (22 mm excursion) needles. Data of 962 biopsied breast lesions were gathered. Surgical follow-up was available for 659 lesions. Breast malignancies were diagnosed by ultrasound-guided LCNB with a sensitivity of 98.2% by performing three cores per lesion. In few cases, the open surgical specimen revealed the presence of invasive carcinomas in contrast to initial LNCB-based classification as ductal carcinomas in situ (DCIS, 11 lesions), lobular carcinoma in situ (one lesion), and atypical ductal hyperpasia (one lesion). Owing to disagreement between classification based on breast-imaging and histological findings, eight of these tumours were subsequently excised. Of the lesions that were removed at the patients' requests despite benign LCNB diagnosis, two were infiltrating carcinoma and one a DCIS. We demonstrate that three 3D-US-guided percutaneous core specimens are sufficient to achieve tissue for a reliable histological assessment of sonographically detectable breast lesions and allow the detection of malignancies with high sensitivity and low rate of false-negative diagnoses.

[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.

[Beta-blocker in secondary prevention of cardiovascular disease]. / Beta-blocker in der Sekundärprävention von Herz-Kreislauf-Erkrankungen.

Since the 1970s beta-blockers are being increasingly used in the treatment of cardiovascular diseases. Many randomized trials have shown a better prognosis of patients under beta-blockade suffering from arterial hypertension and heart failure, after myocardial infarction and left ventricular dysfunction, respectively. Therefore, beta-blockers are an essential part in the treatment of cardiovascular disease.

Measurement of hypoxia using the comet assay correlates with preirradiation microelectrode pO2 histography in R3327-AT rodent tumors.

Polarographic determination of tumor oxygenation by Eppendorf histography is currently under investigation as a possible predictor of radiotherapy outcome. Alternatively, the alkaline comet assay has been proposed as a radiobiological approach for the detection of hypoxia in clinical tumor samples. Direct comparisons of these methods are scarce. One earlier study with different murine tumors could not establish a correlation, whereas a weak correlation was reported for a variety of human tumors. Considering the different end points and spatial resolution of the two methods, a direct comparison for a single tumor entity appeared desirable. Anaplastic R3327-AT Dunning prostate tumors were grown on Copenhagen rats to volumes of 1-6 cm(3). Eppendorf histography (100-200 readings in 5 parallel tracks) for 8 different tumors revealed various degrees of oxygenation, with median pO(2) values ranging from 1.1 to 23 mmHg. Within 5 min after an acute exposure to 8 Gy (60)Co gamma rays, tumors were excised from killed animals and rapidly cooled to limit repair, and a single cell suspension was prepared for use with the comet assay. The resulting comet moment distributions did not exhibit two subpopulations (one hypoxic and the other aerobic), and a hypoxic fraction could not be calculated. Instead, the average comet moment distribution was taken as a parameter of overall strand break induction. Corresponding experiments with tumor cells grown in vitro allowed us to derive the relationship between the oxygen enhancement ratio (OER) for the average comet moment and oxygen partial pressure (Howard-Flanders and Alper formula). The validity of this relationship was inferred for cells exposed in situ, and the convolution of a pO(2) distribution with the formula of Howard-Flanders and Alper yielded an array of expected OER values for each tumor. The average expected OER correlated well with the average comet moment (r = 0.89, P < 0.01), and the in situ comet moment distributions could be predicted from the Eppendorf data when 50% repair was taken into account, assuming a 5-min damage half-life. The findings confirm the potential of interstitial polarography to reflect radiobiologically relevant intracellular oxygenation, but also underscore the confounding influence of differences in repair that may occur when cells are prepared from irradiated tissues for use with the comet assay.