[Comparability of different data sources on stroke care in Germany]. / Vergleichbarkeit unterschiedlicher Datenquellen zur Schlaganfallversorgung in Deutschland.

This article reviews different methodological approaches for determining treatment reality of ischemic stroke patients in acute care hospitals. Considering specific advantages and disadvantages of two different epidemiologic approaches, a specific comparison was carried out of cases from a structured analysis of the nationwide German diagnosis-related groups (DRG) statistics and data from the acute stroke treatment in Hesse (SA_HE) for 2018 collated by the office for quality management. According to the DRG statistics and the SA_HE data, 16,267 and 15,643 acute ischemic stroke patients (ICD code I63) were treated in Hesse in 2018, with 53.7% and 54.5% males, respectively. The overall age distribution did not show significant differences between the two data sources; however, stroke patients over the age of 70 years were registered significantly more often in the DRG statistics. The rates of systemic thrombolysis were 16.5% in both data sources and the rates of mechanical thrombectomy were 5.6% and 5.9%, respectively. The analysis shows that after a rational limitation of the included cases and based on the place of treatment, there were no statistically significant differences concerning the number of hospitalized patients with ischemic stroke, distribution of gender and age as well as the documented rates of systemic thrombolysis and mechanical thrombectomy. It can therefore be concluded that the well-controlled stroke quality register examined is able to capture a sufficient number of hospitalized acute ischemic stroke cases and treatment rates. Therefore, it appears to be recommendable to adopt the strict Hessian guidelines for data acquisition and control nationwide. In this way a nationwide combined analysis of data from the working group of German stroke registers and the DRG statistics would be possible.

[Quality of care of acute ischemic stroke in Germany 2018]. / Versorgungsqualität des akuten ischämischen Schlaganfalls in Deutschland 2018.

In this overview the current quality of acute in-hospital care of stroke patients in Germany in 2018 is described based on standardized and evidence-based quality indicators. For this purpose the reports of the regional quality assurance projects for stroke care, which collaborated within the German-speaking Stroke Registers Study Group (ADSR) were analyzed. Overall, more than 280,000 acute admissions of stroke patients were documented in the included quality assurance projects. The results regarding the defined 16 quality indicators comprising diagnostics, acute treatment, rehabilitation and secondary prevention showed a high level of acute inpatient treatment of stroke in Germany. Only a few quality indicators, such as early transfer for thrombectomy indicated a great necessity for process optimization.

The Oxysterol Synthesising Enzyme CH25H Contributes to the Development of Intestinal Fibrosis.

Intestinal fibrosis and stenosis are common complications of Crohn's disease [CD], frequently requiring surgery. Anti-inflammatory strategies can only partially prevent fibrosis; hence, anti-fibrotic therapies remain an unmet clinical need. Oxysterols are oxidised cholesterol derivatives with important roles in various biological processes. The enzyme cholesterol 25-hydroxylase [CH25H] converts cholesterol to 25-hydroxycholesterol [25-HC], which modulates immune responses and oxidative stress. In human intestinal samples from CD patients, we found a strong correlation of CH25H mRNA expression with the expression of fibrosis markers. We demonstrate reduced intestinal fibrosis in mice deficient for the CH25H enzyme, using the sodium dextran sulphate [DSS]-induced chronic colitis model. Additionally, using a heterotopic transplantation model of intestinal fibrosis, we demonstrate reduced collagen deposition and lower concentrations of hydroxyproline in CH25H knockouts. In the heterotopic transplant model, CH25H was expressed in fibroblasts. Taken together, our findings indicate an involvement of oxysterol synthesis in the pathogenesis of intestinal fibrosis.

Genetic polymorphisms associated with smoking behaviour predict the risk of surgery in patients with Crohn's disease.

BACKGROUND: Smoking is a strong environmental factor leading to adverse outcomes in Crohn's disease, but a more benign course in ulcerative colitis. Several single nucleotide polymorphisms (SNPs) are associated with smoking quantity and behaviour. AIM: To assess whether smoking-associated SNPs interact with smoking to influence the clinical course of inflammatory bowel diseases. METHODS: Genetic and prospectively obtained clinical data from 1434 Swiss inflammatory bowel disease cohort patients (821 Crohn's disease and 613 ulcerative colitis) were analysed. Six SNPs associated with smoking quantity and behaviour (rs588765, rs1051730, rs1329650, rs4105144, rs6474412 and rs3733829) were combined to form a risk score (range: 0-12) by adding the number of risk alleles. We calculated multivariate models for smoking, risk of surgery, fistula, Crohn's disease location and ulcerative colitis disease extent. RESULTS: In Crohn's disease patients who smoke, the number of surgeries was associated with the genetic risk score. This translates to a predicted 3.5-fold (95% confidence interval: 2.4- to 5.7-fold, P<.0001) higher number of surgical procedures in smokers with 12 risk alleles than individuals with the lowest risk. Patients with a risk score >7 had a significantly shorter time to first intestinal surgery. The genetic risk score did not predict surgery in ulcerative colitis or occurrence of fistulae in Crohn's disease. SNP rs6265 was associated with ileal disease in Crohn's disease (P<.05) and proctitis in ulcerative colitis (P<.05). CONCLUSIONS: SNPs associated with smoking quantity is associated with an increased risk for surgery in Crohn's disease patients who smoke. Our data provide an example of genetics interacting with the environment to influence the disease course of inflammatory bowel disease.

Myeloid differentiation primary response gene (MyD) 88 signalling is not essential for intestinal fibrosis development.

Dysregulation of the immune response to microbiota is associated with inflammatory bowel disease (IBD), which can trigger intestinal fibrosis. MyD88 is a key component of microbiota signalling but its influence on intestinal fibrosis has not been clarified. Small bowel resections from donor-mice were transplanted subcutaneously into the neck of recipients C57BL/6 B6-MyD88tm1 Aki (MyD88-/-) and C57BL/6-Tg(UBC-green fluorescence protein (GFP))30Scha/J (GFP-Tg). Grafts were explanted up to 21 days after transplantation. Collagen layer thickness was determined using Sirius Red stained slides. In the mouse model of fibrosis collagen deposition and transforming growth factor-beta 1 (TGF-ß1) expression was equal in MyD88+/+ and MyD88-/-, indicating that MyD88 was not essential for fibrogenesis. Matrix metalloproteinase (Mmp)9 expression was significantly decreased in grafts transplanted into MyD88-/- recipients compared to MyD88+/+ recipients (0.2 ± 0.1 vs. 153.0 ± 23.1, respectively, p < 0.05), similarly recruitment of neutrophils was significantly reduced (16.3 ± 4.5 vs. 25.4 ± 3.1, respectively, p < 0.05). Development of intestinal fibrosis appears to be independent of MyD88 signalling indicating a minor role of bacterial wall compounds in the process which is in contrast to published concepts and theories. Development of fibrosis appears to be uncoupled from acute inflammation.

Rapid Drink Challenge in high-resolution manometry: an adjunctive test for detection of esophageal motility disorders.

BACKGROUND/AIMS: The Chicago Classification for diagnosis of esophageal motility disorders by high-resolution manometry (HRM) is based on single water swallows (SWS). Emerging data suggest that a "Rapid Drink Challenge" (RDC) increases sensitivity for motility disorders. This study establishes normal values and diagnostic thresholds for RDC in clinical practice. METHODS: Two cohort studies were performed in patients with dysphagia or reflux symptoms (development and validation sets). Healthy subjects and patient controls provided reference values. Ten SWS and two 200-mL RDC were performed. Primary diagnosis for SWS was established by the Chicago Classification. Abnormal RDC was defined by impaired esophagogastric junction (EGJ) function (elevated integrated relaxation pressure during RDC [IRP-RDC]); incomplete inhibition of contractility during and ineffective contraction after RDC. Diagnostic thresholds identified in the development set were prospectively tested in the validation set. RESULTS: Normal values were determined in healthy (n=95; age 37.8 ± 12) and patient controls (n=44; age 46.4 ± 15). Development and validation sets included 178 (54 ± 17 years) and 226 (53 ± 16 years) patients, respectively. Integrated relaxation pressure during RDC was higher for SWS than RDC in all groups (overall P<.001), except achalasia. Rapid Drink Challenge suppressed contractility, except in achalasia type III, spasm, and hypercontractile motility disorders (P<.001). An effective after-contraction was present more often in health than disease (P<.001). Optimal diagnostic thresholds identified in the development set (IRP-RDC ≥12 mmHg achalasia, IRP-RDC ≥ 8mmHg "all cause" EGJ dysfunction), were confirmed in the validation set (both, sensitivity ~85%, specificity >95%). CONCLUSIONS: Rapid Drink Challenge contributes clinically relevant information to routine HRM studies, especially in patients with EGJ dysfunction.

Prolonged measurement improves the assessment of the barrier function of the esophago-gastric junction by high-resolution manometry.

BACKGROUND: Etiology of gastro-esophageal reflux disease (GERD) is multifactorial, but incompetence of the esophago-gastric junction (EGJ) appears to be of crucial importance. Established manometric parameters for assessment of EGJ barrier function are sub-optimal, potentially because they reflect only a very brief (up to 30 seconds), not necessarily representative period. This prospective, case-control study tested the performance of novel, high-resolution manometry (HRM) parameters of EGJ function in the assessment of GERD. METHODS: Patients with reflux symptoms and healthy controls (HC) underwent standard HRM and 24-hour pH±impedance measurements. EGJ morphology, lower esophageal sphincter pressure integral (LES-PI), EGJ contractile integral (EGJ-CI) were compared with total-EGJ-CI, a novel parameter summarizing EGJ barrier function during the entire HRM protocol. Esophageal acid exposure ≥4.2%/24 h (A-Reflux-pos) or ≥73 reflux episodes in 24 hours (V-Reflux-pos) were considered pathological. KEY RESULTS: Sixty five HC and 452 patients completed HRM, 380 (84%) patients underwent ambulatory reflux-monitoring. LES-PI, EGJ-CI and total-EGJ-CI correlated with EGJ morphology subtypes (all P<.00001). Only total-EGJ-CI was consistently lower in A-Reflux-pos and V-Reflux-pos subjects compared with HC and patients without GERD. Total-EGJ-CI was also the single best parameter for prediction of pathological reflux (optimal cut-off 47 mmHg cm, AUC 0.746, P<.0001). This cut-off value, approximately 1 SD below the mean normal value, showed modest sensitivity 54% and positive predictive value 46%, but good specificity 85% and negative predictive value 89% for GERD diagnosis. CONCLUSION & INFERENCES: Total EGJ-CI, a new metric that summarizes EGJ contractility over time, allows an improved assessment of EGJ barrier function. Pathological reflux is unlikely if this metric is within the upper two-thirds of the normal range.

[Crew resource management and simulator training in acute stroke therapy]. / Crew-Ressource-Management und Simulatortraining in der akuten Schlaganfalltherapie.

BACKGROUND: Time is of critical importance in acute stroke management. The establishment of thrombectomy now adds to the complexity and interdisciplinarity of the initial phase. In non-medical high-fidelity situations, such as aviation, crew resource management (CRM) has proven to be highly efficient. It has therefore also been implemented in professional cardiovascular life support training. In a setting where every minute counts, CRM and regular training of the high-fidelity stroke team could offer ways to improve treatment of acute stroke patients. OBJECTIVES: We evaluated the effects of a CRM-based stroke team with regular simulation training on the quality of care (e.g. door to needle time and thrombolysis rate) as well as on staff satisfaction and perceived patient safety in the emergency department of a tertiary care neurocenter. MATERIAL AND METHODS: We implemented a dedicated stroke team consisting of 7 persons who are notified by a collective call via speed dial and conceived a simulator-based team training for all new stroke team members which we conduct at monthly intervals. We recorded door to needle times of all consecutive patients, staff satisfaction in the emergency room and the acceptance of this new learning format. RESULTS: This approach led to a relevant and sustained reduction of the mean door to needle time to less than 30 min. It improved perceived patient safety in residents with professional experience of less than 2 years. There was a very high acceptance within the stroke team training and staff and its usefulness was judged to be very high. CONCLUSION: Even though our data do not allow positive effects on patient outcomes to be inferred, the implementation of a CRM-based stroke team and simulator training has had multiple positive effects on the workflow and work satisfaction in the treatment of acute stroke patients.

A population based evaluation of the mode of delivery in association with infertility treatment from 1990-2012.

BACKGROUND: This study refers to population based data and investigates the development of the mode of delivery associated with infertility treatment over the last 23 years. METHODS: All 1 202,557 deliveries in Hesse, Germany, between 1990 and 2012 were assessed. 2.2% of the study population, 26,761, had a delivery subsequent to infertility treatment based on the Hessian Perinatal Registry (HEPE). An evaluation in this subgroup was performed investigating the associations between the mode of delivery and the gestational week and the mother's age. RESULTS: A continuous and significant (p<0.01) increase of cesarean section (CS) rates subsequent to infertility treatment (1990: 41,3%; 2012: 55,9%) as well as a conversely also significant (p<0.01) reduction of vaginal operative and spontaneous deliveries associated with infertility treatment between 1990 and 2012 was found. Furthermore, the preterm delivery rate and the proportion of deliveries of parturients older than 35 years of age in association with infertility treatment raised over the last years. Rates of full-term deliveries and deliveries of women younger than 35 years remained stable during the observation period. DISCUSSION: The rate of cesarean section is continuously rising over the last 23 years with regard to parturients subsequent to infertility treatment. The CS rate is significantly higher compared to women with a spontaneous pregnancy and in comparison to the data from 20 years ago. Most recently, the number of CS (51,2%) exceeded the number of vaginal deliveries (48,8%) in Hesse subsequent to infertility treatment for the first time.

Trends of vaginal birth after cesarean delivery in Germany from 1990 to 2012: a population-based study.

BACKGROUND: The increasing incidence of cesarean deliveries (CD) in the western world is consequently leading to a rising number of antenatal counselling of pregnant women with a history of previous CD. To counteract the increasing trend of cesarean deliveries, the concept of vaginal birth after cesarean delivery (VBAC) may represent an alternative. The aim of the present study was to longitudinally investigate the incidence of VBAC and compare the changes within all deliveries during 23 years of follow-up. METHODS: In this study we analyzed data from 1 202 557 deliveries in Hesse, Germany from 1990 to 2012. In total, 131 629 births have been identified to have at least one CD in the patients' medical history. We grouped the patients into 3 categories: vaginal spontaneous birth subsequent to CD, vaginal-operative birth subsequent to CD and repeated CD. RESULTS: After previous CD, 32.1% of the patients delivered spontaneously, 4.0% delivered vaginal-operative and 63.8% had a repeated CD. The rates changed from 40.4, 7.5 and 52.1% in the year 1990 to 23.3, 2.8 and 73.9% in the year 2012 for vaginal spontaneous births, vaginal-operative births and for repeated CDs, respectively (p<0.01). We noticed a decline of 17.1 and 4.7% in spontaneous births after Cesarean and vaginal operative births respectively during the observation period. Notably, we report a dramatic increase of 21.8% of repeated CDs during the past 23 years (p<0.01). With regard to the non-affected group including all deliveries, we observed a decrease of 17% in spontaneous deliveries from 1990 to 2012 (75.9 vs. 58.9%). Vaginal operative delivery rates changed from 6.9% in 1990 to 5.9% in 2012. Consequently, CD rates increased from 17.2% in 1990 to 35.2% in the year 2012 (p<0.01). The differences between all 3 subgroups were significantly different (p<0.001). DISCUSSION: Cesarean rates in Germany have reached an all-time high, while VBAC follows a continuous decrease. The current rate of VBAC is almost the half of that in the year 1990 (26.1 vs. 47.9%). Promotion of a trial of labor (TOL) after low transverse CD in those women who desire 3 or more children may increase the VBAC success rates and reduce maternal morbidity.

[Mortality of very low birth weight infants during a 24 year period in Hesse a province of Germany - impact of variation in registration]. / Mortalität von Frühgeborenen über einen Zeitraum von 24 Jahren in Hessen - Einfluss veränderter Datensammlung auf die Ergebnisse.

AIM: To study mortality in very low birth weight infants (VLBW) and the impact variation how to register that. METHODS: Data from the Hessian neonatal register from a 24 years period were analyzed. The only outcome criterion was mortality. The whole study time was divided into 6 parts for a period of 4 years. The death rate of preterm infants of 24 weeks of gestation, of those below 24 weeks, and of preterms of 27 weeks was analyzed separately. RESULTS: During 24 years the absolute number of deaths in the group of VLBW increased from an average of 37 patients per year to 60 (p>0.05). The relative mortality decreased from 13.5% to 10.1%. There was an increasing registration of extreme preterm babies of 24 weeks or less. In the last period 13.3% of all VLBW were <25 weeks. These patients represented 54.7% of all deaths in VLBW during 2009-2012. Mortality of preterms of 24 weeks of gestation decreased significantly from 83.3% at the start of the registry to 20.8% in the last period (p=0.007) whereas death rate of preterm infants of 27 weeks dropped from 24.4% to 13.6% (p>0.05). There were also more admissions of extreme preterm infants to neonatal intensive care units. CONCLUSION: Infant death rates are influenced by variation in registration of extreme preterm infants. On the other hand increased registration of these patients seems to encourage doctors to treat them.

A Population-based study on trends in the mode of delivery subsequent to stillbirth, infant mortality and severe infant malformations in the state of Hesse, Germany between 1990 and 2012.

BACKGROUND: Women giving birth to a child with severe infant malformations or suffering a stillbirth certainly experience a mental trauma. Therefore the objective of the present study is to examine the incidence of deliveries subsequent to such a traumatic experience as well as the mode of delivery. Secondly, the results are compared to the changes of a non-affected group of deliveries over the last 23 years in the state of Hesse, Germany. METHODS: The total obstetric dataset of the Hessian Perinatal Registry (HEPE) was assessed for women with regard to one item of the pregnancy risk factors. This particular HEPE item comprises information on the rates of stillbirth, early and late infant mortality (≤7 days,<1 year) as well as severe infantile malformations in women giving birth subsequent to such an extensive traumatic experience. The identified women were categorized with respect to the mode of delivery (spontaneous, vaginal operative or Cesarean section), pre- and full-term birth and according to 4 time-frames between 1990 and 2012. The results of women with a positive HEPE item were compared to those of women without such a traumatic experience (non-affected group) of the HEPE analyzed in the same categories and time-frames. RESULTS: The obstetric dataset from 1990 until 2012 of the HEPE comprised altogether 1 224 760 deliveries including a group of 19 726 (1.61%) deliveries subsequent to a positive result for the analyzed HEPE item. Over the duration of follow-up the rate of subsequent pregnancies following such a traumatic experience showed a significantly decrease of 43% in comparison to the previous time-frame, respectively (1990-1996: 30.3%; 2008-2013: 17%; P≤0.0001). With respect to the mode of delivery (spontaneous, vaginal operative, Cesarean section) the results in the group subsequent to the positive HEPE item (1 862, 55.5%; 70, 2.1%; 1 416, 42.2%) were significantly different (P<0.001) in comparison to the non-affected group (142 846, 59.9%; 13 875, 5.8%; 81 089, 34.0%), respectively. DISCUSSION: Rising rates of CSs and conversely decreased numbers of vaginal deliveries in most cases of full-term pregnancies contrast with the reduction of the positive HEPE item over the last 23 years. There seems to be an urgent need for action since this observed critical trend remains highly significant in comparison with the rising trend of CS in general. Pre-pregnancy counseling and continuous monitoring during pregnancy and delivery in consciousness of evident risk factors may be an opportunity to cope with these serious findings.

Disease Management Project Breast Cancer in Hesse - 5-Year Survival Data: Successful Model of Intersectoral Communication for Quality Assurance.

Introduction: The Disease Management Project Breast Cancer (DMP Breast Cancer) was first launched in Hesse in 2004. The project is supported by the health insurance companies in Hesse and the Professional Association of Gynaecologists in Hesse. The aim is to offer structured treatment programmes to all women diagnosed with breast cancer in Hesse by creating intersectoral cooperations between coordinating clinics, associated hospitals and gynaecologists in private practice who registered in the DMP programme. Method: Between 1 January 2005 and 30 June 2011, 13 973 women were enrolled in the DMP programme. Results: After data cleansing, survival rates were calculated for a total of 11 214 women. The 5-year overall survival (OS) rate was 86.3 %; survival rates according to tumour stage on presentation were 92.2 % (pT1) and 82.3 % (pT2), respectively. The impact of steroid hormone receptor status on survival (87.8 % for receptor-positive cancers vs. 78.9 % for receptor-negative cancers) and of age at first diagnosis on survival (≤ 35 years = 91 %) were calculated. Conclusion: The project showed that intersectoral cooperation led to significant improvements in the quality of treatment over time, as measured by quality indicators and outcomes after treatment.

Histopathological evidence of invasive gastric mucormycosis after transarterial chemoembolization and liver transplantation.

We describe a case of a 62-year-old diabetic woman with hepatocellular carcinoma due to chronic hepatitis B virus infection. Two weeks after orthotopic liver transplantation, endoscopy for massive upper gastrointestinal bleeding revealed a large necrotic area in the gastric fundus. The patient underwent emergency resection. Histopathologically, angioinvasive mold infection compatible with mucormycosis was diagnosed in a large area of necrosis, mimicking an atypically localized gastric ulcer. Foreign bodies originating from transarterial chemoembolization (TACE) performed 7 and 8 months earlier and 40 days before transplantation were identified in the submucosal tissue. The patient was treated with liposomal amphotericin B (LAB) for 5 weeks, followed by 7 weeks of posaconazole. Follow-up biopsies after 1 and 5 months confirmed successful treatment. Review of the radiological images of the TACE procedure showed that some of the TACE material had been diverted to the stomach via an accessory gastric branch originating from the left hepatic artery. TACE agents may be associated with chronic, refractory gastroduodenal ulcers. We hypothesize that the ischemic lesion was first colonized with presumed Mucorales mold and invasive growth was promoted by the posttransplantation immunosuppression. Careful exploration of extrahepatic collaterals during TACE may prevent this complication.

Toward more accurate measurements of anorectal motor and sensory function in routine clinical practice: validation of high-resolution anorectal manometry and Rapid Barostat Bag measurements of rectal function.

BACKGROUND: Measurements of anorectal function using high-resolution anorectal manometry (HR-ARM) and rectal barostat technology provide more reliable results than standard ARM with an elastic balloon; however, HR-ARM results have not been compared to ARM and standard barostat protocols are impractical in routine clinical practice. The aim of this study was to validate HR-ARM against standard ARM and standard barostat against a novel Rapid Barostat Bag (RBB) measurement and elastic balloon measurements of rectal function. METHODS: Twenty-six healthy volunteers (15 female, 11 male, 19-52 years) were studied. Measurements of anal function and simulated defecation were compared for 12-sensor HR-ARM and 6-sensor standard ARM using line plots from the same recording. Rectal capacity, compliance, and sensation (volume threshold) were measured by elastic balloon, standard barostat, and RBB methods using stepwise inflation of a 700-mL polyethylene bag to 40 mmHg distension by electronic barostat and handheld syringe monitored by sphygmo-manometer, respectively. Results are reported as mean ± SD. Bland-Altman plots and correlation coefficients (r) for measurements were calculated. KEY RESULTS: There was excellent agreement between HR- and standard ARM measurements (r > 0.86, <25 mmHg difference) and between standard barostat and RBB measurements of rectal capacity (r = 0.97, <25 mL difference). Correlation coefficients of threshold volumes for initial perception, urgency and discomfort were 0.37, 0.71, and 0.95, respectively. No significant correlation was present with elastic balloon measurements. Time to complete studies was shorter for HR-ARM than standard ARM and for RBB than standard barostat in historical controls. CONCLUSIONS & INFERENCES: HR-ARM with RBB measurements of anorectal function provides quick and reasonably accurate measurements of continence function suitable for use in routine clinical practice (ClinicalTrial.gov NCT01456442).

Rising cesarean rates of twin deliveries in Germany from 1990 to 2012.

In the past 2 decades there has been an increasing trend for cesarean deliveries in twin pregnancies associated with increased maternal and fetal morbidity and mortality.We analyzed the mode of delivery of 18,132 twin gestations from the perinatal survey of Hessen in Germany between 1990 and 2012 and divided them into 4 categories according to the week of gestation (<28, 28-31, 32-36, >36). We further analyzed the cesarean delivery rates for the same period depending on the institutional level and divided them into 3 categories - University hospitals with perinatal center (U/PS), non-university affiliated hospitals with perinatal center (NU/PS) and smaller clinics without perinatal unit (NU/NPS).Cesarean rates changed from 63.6% (< 28), 88.9% (28-31), 59.6% (32-36) and 40% (> 36) in the year 1990 to 74.2%, 95.5%, 76.9% and 68.7% in 2012, respectively. As such, we report an overall increase of 23.5% in cesarean deliveries of twins over the last 23 years. We find an overall increase of 16.8%, 21% and 22.1% in university hospitals with perinatal units, in non-university hospitals with perinatal unit and in smaller hospitals without perinatal units, respectively. Furthermore, combined cesareans increased from 3.9% in 1990 to 7.0% in 2012.These findings indicate a dramatic increase in cesarean delivery rates for twin births from 1990 to 2012. We discuss the importance of international compatible guidelines for the conditions and technical procedures for twin deliveries.

Time trends in systemic thrombolysis in a large hospital-based stroke registry.

BACKGROUND: Systemic thrombolysis for acute stroke was approved by German authorities in 2002. While recombinant tissue plasminogen activator (rtPA) use first remained low, systemic thrombolysis is nowadays an established part of common stroke care. The purpose of this study was to determine changes in systemic thrombolysis rates within an observation period of 7 years following the approval of rtPA therapy in Germany in a large state-wide stroke data set. METHODS: We analyzed a prospective hospital-based stroke registry covering the entire federal state of Hesse, Germany. All hospitals providing stroke care in Hesse (neurology hospitals and hospitals for internal medicine) are obligated to register all inpatients. All cases admitted between 2003 and 2009 with a final diagnosis of ischemic stroke (ICD-10: I63) were selected. We analyzed the relationship between thrombolysis rates, onset-to-admission time (hospital arrival ≤3 and >3 h after symptom onset), patient age (quartiles and dichotomized in ≤80 and >80 years) and disability at admission (assessed by the Rankin Scale). A one-way ANOVA with Bonferroni correction for multiple comparisons was performed to test for significant changes during the observation period. RESULTS: 88,340 patients with ischemic stroke were identified. Thrombolysis rates increased continuously from 2.5% in 2003 to 8.4% in 2009. In patients admitted within 3 h after symptom onset, the thrombolysis rate was 2.5-fold higher in 2009 (25.4%) as compared to 2003 (10.5%). The mean age (±SD) of thrombolyzed patients increased from 68.7 (±11.5) years in 2003 to 70.7 (±13.4) years in 2009 (p for trend = 0.014), but remained stable in the entire cohort. 20.1% of all systemic thrombolytic treatments were performed in patients >80 years old. Disability at admission decreased more pronouncedly in rtPA-treated patients (Rankin Scale score 0-2: 15.2% in 2003 and 24.5% in 2009; p for trend <0.001) as compared to the entire cohort (34.5% in 2003 and 41.5% in 2009; p for trend <0.001). CONCLUSIONS: Thrombolytic therapy is increasingly used in acute stroke, particularly in patients admitted within the 3-hour time window. Higher treatment rates are at least partially explained by spreading rtPA application, including older and less severely affected patients. Approximately one fifth of all rtPA treatments were given to the very old (>80 years), which is outside the age limit for rtPA approval. In the light of upcoming demographic changes, the proportion of very aged stroke patients will increase substantially, further tightening the current discussion of an upper age limit for thrombolytic therapy.

[Regionalised perinatal care in cases of cervical incompetence and imminent premature birth]. / Regionalisierung und Prolongation der Schwanger-schaft bei Cervixinsuffizienz.

INTRODUCTION: Premature birth due to cervical incompetence is a major obstacle of perinatal medicine. While measures of prevention have been investigated, the mother should be transferred to a perinatal centre when delivery < 34 + 0 weeks is imminent. Delivery in the state of Hessein the large majority of case is performed by medically indicated CS: We evaluated the potential prolongation of gestation in relation to the level of the institute. METHODS: In order to evaluate the influence of the level of the obstetrical institute on the prolongation of pregnancy we used the data set of the Hesse perinatal survey (HEPE) of the years 1990 − 2009 (n = 449 933). A multivariate analysis excluding the confounders prematurity, IUGR,and maternal disease was performed to evaluate the relation of prolongation of gestation to the level of care. RESULTS: Admissions with imminent premature birth due to cervical incompetence were identified in 6 892 cases. Overall prolongation until birth was 9.6 days. When the cervical incompetence was < 3 cm the difference between hospitals was not significant (12.7 vs. 13.1 d) days. With the cervix ≥ 3 cm the period after admission was merly 0.6 day in level I hospitals − thus significantly lower than in perinatal centres (6.5 days). CONCLUSION: In order to achieve optimal conditions at birth for very premature newborns the organisation of perinatal care should aim at intrauterine transfer to a specialised perinatal unit.A precondition is a health system with an adequate structure of perinatal centres within 30 k min the case of obstetrical emergencies