Primary breast cancer therapy in six regions of Germany.

Studies from six regions of Germany (Aachen (W1), Dresden (E1), Jena (E2), Marburg (W2), Munich (W3), and Stuttgart (C1)) have been compared to verify and assess the quality of healthcare using breast cancer as an example. All of the data collection was carried out in comprehensive cancer centres and is population-based, with the exception of C1. Classic prognostic factors and the initial treatment of 8661 women with breast cancer, diagnosed between 1996 and 1998, were examined. Primary therapy, breast conserving therapy (BCT), and the use of subsequent local radiation and/or systemic therapy (chemotherapy or hormonal therapy) were analysed. BCT was performed on 39.3-57.7% of patients. By pT-category, the proportion of BCT in the six regions were as follows: for pTis between 37.8 and 64.3%, for pT1 between 51.7 and 71.5%, for pT2 between 25.9 and 51.1%, for pT3 between 0 and 13.1% and for pT4 between 0 and 15.2%. Multivariate analyses, adjusted for age and biological factors, showed a significant influence of the treating hospital on the mastectomy rate. The use of radiotherapy after BCT (80%) was quite homogeneous in the six regions. The application of radiotherapy after mastectomy, however, varied between 10.4 and 32.2%. In all regions, for premenopausal patients, the use of adjuvant systemic therapy almost reflected the St. Gallen-Consensus recommendations. In contrast, post-menopausal women with positive lymph nodes were not always treated according to these standards. In all regions, age had an influence on the administration of treatment: elderly breast cancer patients received less BCT, less radiotherapy and less adjuvant therapy than recommended in the St. Gallen-Consensus. Feedback of the results was made available to each hospital, providing a comparative summary of patient care that could be used by the participating hospitals for self-assessment and quality-control.

Carpal tunnel syndrome--course and prognosis.

In a retrospective study 157 patients with electrophysiologically proven carpal tunnel syndrome (CTS) were followed up. Of the 85 operatively treated patients, 86% showed clear improvement or cure, as did 32% of the patients not operated upon. Multivariate analysis of variance (MANOVA) and linear discriminant analyses indicated atrophy and length of history as effective predictors of clear improvement. The optimized discriminant point was ascertained in the receiver operator characteristics (ROC) curve. A predictive value of positive test of 0.89 was found for the course form "not cured" and a predictive value of negative test of 0.75 for the course form "cured" with a prevalence of one-third for the good course form. The prognosis was bad if atrophy occurred or the history exceeded 7 months. The determination of distal motor latency is indispensable for diagnosing CTS. For prognosis, however, length of history and clinical findings have been more helpful.

Recommendations of the German Association for Medical Informatics, Biometry and Epidemiology for education and training in medical informatics.

In the fields of health care and medicine there is an immense demand for a systematic application of methods of information processing and for the use of computers. Obviously, to that end well-trained scientists and qualified personnel must be available. With the present recommendations on education and training in medical informatics the German Association for Medical Informatics, Biometry and Epidemiology (GMDS) proposes structure and contents of medical informatics curricula and courses. The recommendations describe a 2-dimensional educational framework with different education levels in one dimension and various types of educational needs and orientation in the other one. The recommendations comprise at the university level education as well specialized curricula covering the total spectrum of medical informatics as well as informatics curricula with medical informatics as integrated applied subject or subsidiary subject, respectively. Besides these informatics-oriented approaches medical-oriented programs of education in medical informatics are recommended, e.g., post-graduate education in medical informatics for physicians based on foundations in medical informatics as part of their initial training in medicine. At the level of polytechnical schools curricula of medical documentation and informatics and at the level of professional schools training in medical documentation are recommended. This report is a translation of its German original. Although considered by the GMDS as recommendations for the Federal Republic of Germany, the text may also contribute to the development of an international, especially European framework of training in medical informatics.

Nasal polyposis, bronchial asthma and analgesic intolerance.

A retrospective case-control study was conducted in 1042 arbitrarily selected bronchial asthma patients (197 patients with AIA and 845 controls with normal analgesic tolerance). Two thirds of all AIA patients reported one or more diseases in the region of the upper airways. Quite different from the control group, highly significant coincidence of AIA with nasal polyposis (42.6%), paranasal sinus diseases (39%), and chronic rhinitis (42,1%) was recorded in the AIA patients. AIA was characterized by stronger inclination to recurrence of nasal polyps and more frequent negative impact of polypectomy upon the course of asthma. The classical triad of "intrinsic asthma - nasal polyps - analgesic intolerance" was established in 39% of the AIA patients. The pathogenetic factors causing the association of asthma with polyps and the even more strongly association of AIA with polyps are still unknown. The presumed pathogenetic relationship between chronic hyperplastic alterations in the upper airways and the phenomenon of AIA might be caused by disorders in phospholid metabolism (liberation of arachidonic acid, lipoxygenase products, radical mechanisms).

[Medical guidelines for diabetes mellitus in Saxony. An instrument for interdisciplinary quality management for optimizing patient care]. / Arztliche Leitlinien Diabetes mellitus in Sachsen. Instrument interdisziplinären Qualitätsmanagements zur Optimierung der Patientenversorgung.

Patients with diabetes still have a life expectancy of 5-10 years less and a markedly reduced quality of life than non-diabetic persons. Concepts, models, and contracts aiming at an efficient co-operative care for chronically ill patients have been developed in the new German states to overcome shortage of care. The dual care of motivated diabetic patients by family physicians and experts for metabolic diseases has proven to be efficient both in pilot studies as well as in country-wide investigations. A representative commission for diabetes has developed guidelines for such a structure of dual care. Design and content of these regional developed guidelines about an cooperative evidence based care for diabetic patients fulfills the criteria suggested by international bodies of experts and the medical society for quality assurance. The Saxonian guidelines for diabetes have been successfully implemented step by step in medical offices and hospitals. We are sure that the further implementation of the shared care system diabetes will further improve quality of care.

Development of an oncology data network in Germany.

In the 1990ies, an oncology data network has been set up mainly in the New States of Germany. Although not formally planned and established as a whole, it consists of a number of initiatives, that co-operate well and gain added value from this co-operation. From the technological view, the centre of the network is the Giessener Tumordokumentationssystem (GTDS), that was developed at Giessen University. We present important basic conditions in which this development took place, show some results and describe future directions of the development.

Investigations on biochemical properties of milk-clotting enzymes.

The properties of proteolytic enzymes produces from calf maws and from an Ascomycete were studied. Both milk-clotting proteases have their optimum activity at pH 5.2 and 45 degrees C. The microbiological rennin has a second maximum activity at pH 3.5 and 55 degrees C. Temperatures above 55 degrees C cause a rapid decrease of activity. The behaviour of enzyme activity is similar with varying substrate and enzyme concentrations. However, increasing amounts of enzyme in ratio to the substrate lead to reaction rates of the calf rennin differing clearly from that of the microbiological rennet complex.

[Urodynamic results before and after operative treatment of stress incontinence in the female]. / Urodynamische Resultate vor und nach operativer Behandlung der Stressinkontinenz der Frau.

On the basis of the urogynaecological results of 66 women before and after vaginal hysterectomy with plastic operation of the diaphragm who were controlled by means of the complex diagnostics programme of incontinence of urine a separation in women who were cured after operation and such ones who post-operatively remained incontinent. Furthermore, the pre- and postoperative data of 6 women were compiled who were treated with an abdominovaginal loop plastics. The results with the references to literature are discussed.

[Epidemiologic aspects of disability caused by rheumatic diseases in the Gera district, East Germany]. / Epidemiologische Aspekte der Invalidität infolge rheumatischer Erkrankungen im Bezirk Gera, DDR.

In the period 1968-1977, the mean annual invalidization rates due to rheumatic diseases in the district of Gera are 36.6 for the female insured population, 19.3 for the male one, per 10(5) persons. After the age of 40, invalidization rates are rising steeply. Degenerative arthropathies (osteoarthroses and displacements of the intervertebral disk or vertebrogenic pain syndromes) constitute more than four fifths of all first-time invalidizations. First-time invalidization was done, on average, 7 years before reaching the age-limit provided by law for old-age pension, in one third temporally limited. The longitudinal monitoring of the invalidzation rates supports the hypothesis that clinical manifestations of degenerative arthropathies are increasing.

[Relevance of urethral pressure profile to diagnosis of stress incontinence (author's transl)]. / Der Wert der Urethradruckprofils bei der Diagnostik der Stressinkontinenz.

Reference is made to the relevance of urethral pressure profile and its parameters, on the basis of urethrocystometric checks of 34 control patients and of another 44 women who had had to undergo surgery for urinary incontinence. In cases of urinary stress incontinence, values prior to surgical treatment generally were lower, but some of the parameters were (statistically insignificantly) enhanced by the operation. - The conclusion is that the urethral pressure profile at rest and under stress (with coughing provoked) provides a more consistent indication of surgery. Yet, accurate diagnosis is not possible on the basis of such examination alone.

[Determination of pregnancy duration following terminated hormonal contraception]. / Zur Beurteilung der Schwangerschaftsdauer nach beendeter hormonaler Kontrazeption.

The duration of pregnancy as assessed by the rule of Naegele was significant different between patients who became pregnant following termination of oral contraception and patients, who had not taken oral contraceptives. The intervall between stopping the pill and pregnancy was two month. We found a relatively high pregnancy rate in the first three month. The clinical significance is discussed.

PIP: The duration of pregnancy was determined for 308 women who became pregnant during the 1st, 2nd, or 3rd months after discontinuing oral contraceptive (Ovosiston, Non-Ovlon) use. The data were compared to those from a control group of 43 women who had not used oral contraceptives prior to conception. An increase in the duration of pregnancy of ca 3-5 days was observed among those who became pregnant during the first 2 months after discontinuing contraceptive use. The pregnancy duration for those who became pregnant in the 3rd month after discontinuing contraceptive use was similar to that of the control group. A wider range in pregnancy duration was observed among patients who had used oral contraceptives prior to conception.

[Monitoring and delivery of the premature infant in breech presentation]. / Uberwachung und Entbindung des unreifen Beckenendlagenkindes.

We explored 183 deliveries in breech presentation. The birthweights from this offsprings were 1941 +/- 418,1 g. 101 were primiparae. The perinatal mortality of the underweigth fetuses was 5 more higher when delivered vaginally in relation to delivery by caesarean section. These differences were statistically significant (p less than 0,05). In relation to multiparae 71,8% of the offsprings survived when delivered vaginally, in comparison to 79,2% offsprings from primiparae. The APGAR-scores (1 and 5 min. p. p.) less than or equal to 7 or greater than or equal to 8 showed no significant differences by the offsprings delivered vaginally or by caesarean section. The pHNA was higher in the group of children, delivered by means of caesarean section. The conclusions are discussed.

Manifest diabetes and keratoconus: a retrospective case-control study.

PURPOSE: To assess the influence of diabetes on the development of keratoconus to show whether biomechanical effects are also reflected in epidemiology. The two diseases have opposite impact on the biomechanics of the corneal stroma: manifest diabetes stiffens the cornea, whereas keratectasia weakens the tensile strength of the stroma. METHODS: The retrospective case-control study included files of 1,142 patients, with 571 patients in the case group (keratoconus patients) and 571 in the control group (clinical population). The groups were well matched with respect to sex and age. We established the number of diabetics in both groups and compared it statistically by means of the odds ratio to determine whether diabetes can be interpreted as having a "protective effect" whether it is a "risk factor" for the development of keratoconus. RESULTS: Two patients of the keratoconus group had manifest diabetes that developed many years after the diagnosis of keratoconus, while nine cases of diabetes were found in the control group. Statistical analysis revealed a strong protective effect of manifest diabetes regarding keratoconus (odds ratio = 0.2195, P = 0.034). This effect was evident only in type II diabetes patients. CONCLUSIONS: The protective effect of manifest diabetes may be explained by the induction of cross-links in the stroma, preventing biomechanical weakening of the cornea. This study shows that different biomechanical changes can be superimposed and assume epidemiological relevance.

[Jena longitudinal study of growth of 0-3 year old children. 1: Average values of body height and body weight, somatograms and percentile values]. / Jenaer Längsschnittstudie über das Wachstum 0-3jähriger Kinder. Teil 1: Mittelwerte der Körpergrösse und des Körpergewichtes, Somatogramme und Perzentilwerte.

Normal values (means +/- s and percentiles) for body height and weight and a somatogram for children from the newborn period up to 3 years determined in 306 children (164 boys and 142 girls) are presented. Beyond the first year of life the children are slightly taller and have a reduced height related body weight in comparison to older standards.

[Exploratory studies of the common incidence of cholelithiasis, status following cholecystectomy and colonic cancer]. / Explorative Untersuchungen zum gemeinsamen Vorkommen von Cholelithiasis, Zustand nach Cholezystektomie und Kolonkarzinom.

For studying the postulated relationship between prior cholecystectomy, cholelithiasis, and occurrence of subsequent colorectal cancer, we examined in a retrospective study autopsy cases to get information about the frequency of them. The material consisted of 10,000 cases (female:male = 1,08:1) with an age maximum in the 8. decennium. Among them were 2457 (902 male and 1555 female) cases of cholelithiasis and 646 (211 male and 435 female) cases of cholecystectomy. 449 colorectal cancer were found, altogether. The incidence of cancer in cases without gallbladder disease amounts to 4.13%, in cases with cholelithiasis 5.37%, and after cholecystectomy 4.95%, respectively. The results must be discussed with care because Berkon's Fallacy. Further exploratory investigations are necessary.

[Personal experiences with conservative drug therapy of urgency symptoms in the female]. / Unsere Erfahrungen mit der konservativ-medikamentösen Therapie der Drang-Symptomatik der Frau.

On the basis of clinical and urodynamic results the authors adopt a definite attitude to the treatment of the urgency syndrome in the woman with the anticholinergic drug propiverin hydrochloride (Mictonorm). The results show a satisfactory improvement in 42 of 68 women (= 62%), whereas 24 of 68 women (= 35%) reported a subjective improvement of the clinical symptoms. These results correspond with the data from literature. In 15 women with no satisfactory effect the beta 2-sympathicomimetic drug clenbuterol (Contraspasmin) was additionally applied. There was a satisfactory success under this medication in 11 of the 15 women (= 72%). The results are discussed with the references of the literature to the conservative therapy of the urgency syndrome.

[Changes in the parameters of the urethral pressure profile by measuring the patient in supine and sitting position]. / Veränderungen der Parameter des Urethradruckprofils bei Messwertaufnahme in liegender oder sitzender Position der Patientin.

For testing the influence of the examination position on the parameters of the urethrocystometry 124 findings of urethrocystometry of 103 female patients were evaluated in 3 groups. In these cases slight alterations develop when changing between lying and sitting position, whereby in sitting position a greater differentiation of an existing component of stress incontinence becomes possible. On the basis of our examination findings and the references in literature it seems to be advisable to perform the urethrocystometry in the same session both in lying and in sitting position for further improvement of the indication for therapy.

[Improvement of care for diabetics using the care model from Saxony]. / Verbesserung der Versorgung von Diabetikern durch das sächsische Betreuungsmodell.

BACKGROUND AND OBJECTIVE: By promoting the networking of all those involved in caring for diabetics in Saxony, through agreement between those who provide help to them and the organizations which pay the costs, the intention is to improve the overall quality of care of diabetics. It was the aim of this study to evaluate the effectiveness of this integrated health model. PATIENTS AND METHODS: As part of the 3rd Diabetes Agreement in Saxony, a total of 275,804 diabetics were registered, treated and their management costed in the first quarter of 2000 and the fourth quarter of 2001 (56.3% females, 43.7% males; median age 68,7 years). They were patients of 2800 general practitioners and 88 specialist practices. RESULTS: Nearly 80% of all diabetics were included. Taking the level of HbA1c as the criterion of quality achieved, it had decreased from 7,1 +/- 1,3 % in the first 3 months of 2000 to 6,8 +/- 1,3 % in the last 3 months of 2001, and regional differences had been reduced. There was an obvious correlation between early referral to specialist practices and good treatment results, as measured by HbA1c and blood pressure levels. While in 1996 patients were referred when the HbA1c level was 8.8% (median 8.5%), referrals in the last quarter of 2001 were made when the mean was 8,0% (median 7.7%). After two years the risk of inadequate treatment (HbA1c > 7.5% and blood pressure > 140/90 mmHg) had been clearly reduced in about half the cases. CONCLUSIONS: Diabetes agreements, as promulgated in Saxony, have provided effective disease management programs (DMP) for efficacious and efficient integrated diabetic care, so that with continuing effectiveness and further development the St. Vincent targets can be reached. Successful regional diabetes agreements must therefore be maintained within the new, politically centralized, DMPs.

[Computerized analysis of intrapartum cardiotocograms]. / Untersuchungen zur rechenautomatischen CTG-Analyse sub partu.

307 monitored labors were investigated by means of a discrimination function (DF) in relation to qualitative CTG-parameters. In this connection we could confirm on the one hand well defined qualitative CTG-criteria in their clinical importance by computation corresponding to "normal", "prepathological" (warning-signs) and "pathological" (signs of hypoxia). On the other hand we could demonstrate the exactly recognition of qualitative CTG-parameters in attendance of computation. The boundary ranges of discrimination function resulting from the automatic CTG-analysis respecting fetal condition turned out to be reproduced and clinically reliable. The prediction with regard to neonatal parameters (pHNA, APGAR-score 5 minutes after delivery) is justifying the employment of present soft ware in clinical practice.