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The Federal Joint Committee of Germany defined structural and staff requirements for the care of preterm and term infants as a proxy measure for quality. Neonatal outcome has been evaluated as a quality marker for a long time. While Germany has one of the highest preterm birth rates in Europe, no data exist on centre-specific preterm birth rates.Over 2 years, all pregnant women admitted to six centres for perinatal medicine in Baden-Württemberg at a gestational age between 22+0 and 31+6 weeks were eligible (n=2972). The preterm birth rate before 32 wks of gestation was evaluated if at least one of the following secondary inclusion criteria was present within 24 h after admission: 1) premature rupture of membranes, 2) cervical length less than 25 mm, or 3) more than 3 contractions of at least 30-s duration within a 30-min period. Neonatal outcome could be documented for 70.6% of infants.Of the women who met at least one secondary inclusion criterion (n=1325), 21.1% (n=279) delivered 344 preterm infants before 32 weeks. The preterm birth rate was between 16.8 and 27.9% (11.1% difference). A lower preterm birth rate was not associated with a worse neonatal outcome.Preterm birth rate should become a quality indicator for perinatal care. A reduction of the preterm birth rate of 5% could help to reduce the number of preterm infants by up to 2,400 per year in Germany (about 25%).Zur Qualitätssicherung der Versorgung Früh- und Reifgeborener wurden vom Gemeinsamen Bundesausschuss umfangreiche Struktur- und Personalvorgaben formuliert. Die Ergebnisqualität für das neonatale Outcome wird bereits seit langer Zeit erhoben. Obwohl Deutschland einer der höchsten Frühgeburtenraten in Europa aufweist, existieren bislang keine zentrumsspezifischen Daten zur Frühgeburtenrate.An 6 Perinatalzentren Level 1 in Baden-Württemberg wurden über 2 Jahre alle Schwangeren erfasst, die mit einem Schwangerschaftsalter zwischen 22+0 und 31+6 Wochen in der Frauenklinik aufgenommen wurden (n=2972). Sofern sie innerhalb von 24 h nach Aufnahme mindestens eines der folgenden sekundären Einschlusskriterien 1. Gesicherte Amnionruptur, 2. Zervixlänge25 mm oder 3. Tokogramm mit3 Wehen von je mind. 30 sec. Dauer in 30 min erfüllten, wurde die Frühgeburtenrate vor 32+0 Schwangerschaftswochen bestimmt. Für 70,6% der Frühgeborenen konnte das neonatale Outcome erhoben werden.Bei 21,1% (n=279) der Schwangeren, die mindestens ein sekundäres Einschlusskriterium erfüllten (n=1325), kam es vor 32+0 SSW zur Geburt von 344 Frühgeborenen. Die Frühgeburtenrate lag zwischen 16,8 und 27,9% (Differenz 11,1%). Eine niedrigere Frühgeburtenrate war nicht mit einem schlechteren neonatalen Outcome vergesellschaftet.Um die Ergebnisqualität eines Perinatalzentrums beurteilen zu können, sollte die Frühgeburtenrate als Qualitätsindikator Einzug finden. Eine Reduktion der Frühgeburtenrate um 5% könnte die Zahl der Frühgeborenen1500 g Geburtsgewicht in Deutschland um 2400/Jahr (ca. 25%) reduzieren.

With an increasing number of cancer survivors quality of life (QoL) becomes more and more important in the treatment of rectal cancer (RC). QoL after sphincter-preserving anterior resection (AR), however, was found nonsuperior to abdominoperineal resection. The aim of our study was to evaluate QoL after AR compared with colon cancer patients after right hemicolectomy (CC) and healthy lay persons without history of cancer (HL) in long-term follow-up.Consecutive alive RC patients (n = 293) who received an AR between 1998 and 2008 were included. CC patients (n = 201) and HL of the same age were used as a surgical and a nonsurgical control group, respectively. QoL was assessed using European Organization of Research and Treatment of Cancer questionnaires QLQ-C 30 and -CR 38.Questionnaires from 116 RC patients, 105 CC patients, and 103 HL were evaluable with a median time after surgery of 5 years. The global health status did not differ. Social functioning, future perspectives, and financial difficulties tended to poorer scores in the cancer groups. Physical functioning was better in RC and CC patients compared with HL. Defecation problems and diarrhea were more frequent in RC patients (P.05). An additional open question revealed a median stool frequency of 3, 2, and 1 per day for RC, CC, and HL, respectively. Defecation problems were more frequent in RC patients who received radiation therapy (P.05).Diarrhea and defecation problems impaired QoL after AR for RC, which was worsened after radiation therapy. To improve QoL of RC patients in the future, physicians have to focus on minimization of gastrointestinal side effects while optimizing surgical reconstruction.

Study design Experimental in vivo study. Objective The objective was to investigate the balance control in patients with acute QTF grade II whiplash injuries of the cervical spine. Summary of background data Tetra-ataxiametric posturography in chronic pain patients after whiplash injuries of the cervical spine has revealed an impaired regulation of balance. However, so far it is unclear if this is caused by the accident or other factors that are associated with the pain chronification process. Methods 40 patients with acute QTF grade II whiplash injuries and 40 healthy matched controls were examined on a posturography platform. The stability index ST Σ and the Fourier analysis FA Σ (0.10–1.00 Hz) were established for eight standing positions and sum scores were calculated. The pain index was established using a visual analog scale ranging from 0 to 100. A follow-up examination was conducted for the patients after 2 months. Results The patients with acute whiplash injuries of the cervical spine achieved significantly poorer results for both ST Σ and FA Σ than the healthy controls. There were no differences between the eight standing positions for both ST Σ and FA Σ . After 2 months, 17 patients had no change in the pain development, 21 patients showed an improvement in pain intensity and 2 patients had deteriorated. The subgroup of patients with improvement in pain intensity showed a significant improvement in balance control concerning the FA Σ compared to patients with unchanged pain intensity. Conclusion Patients with acute whiplash injuries have a reduced balance control as compared to matched controls. This study gives an indication that post-traumatic neck pain is associated with impairments of postural control.

Colorectal cancer is one leading cause of cancer-related death worldwide, and distant metastases determine an unfavorable prognosis. Surgical resection of colorectal liver metastases (CRLM) improves survival and provides the chance for cure. The aim of this study was to prospectively analyze the outcome of patients with CRLM in a population-based manner, and thereby, to compare the prognosis of patients undergoing resection with those receiving nonsurgical treatment. Moreover, we set out to identify and confirm important prognostic factors after resection of CRLM.We analyzed the outcome of 506 patients diagnosed with CRLM in our institution from 1996 to 2011. Survival and the impact of clinical and pathologic factors were analyzed by univariate analysis. Important independent prognostic factors were analyzed by multivariate analysis.The 5-year overall survival rate (5y-OSR) for patients receiving resection of CRLM (n = 152) was 46% (95% confidence interval (CI), 37%-54%) compared with a 5y-OSR of 6% (95% CI, 4%-9%) for patients treated nonsurgically (n = 354). There was no perioperative mortality. Multivariate analysis revealed, among other factors, good performance status of the patient (low American Society of Anesthesiologists score), the absence of extrahepatic metastases, 5 metastatic lesions, and a tumor-free resection margin (R0) as important, independent prognostic factors. Importantly, repeated hepatic resections of CRLM performed in 13 patients were associated with an excellent outcome (5y-OSR, 47%; 95% CI, 17%-72%).Surgical resection, which can be performed with tolerable site-effects, is the first choice for patients diagnosed with metachronous and synchronous CRLM. Of note, repeated resections should be advised in recurrent intrahepatic colorectal cancer whenever possible.

Adjuvant treatment is still controversially discussed for elderly colon cancer (CC) patients. Our aim was to investigate the benefit of adjuvant treatment for younger (70 years) and elderly (≥70 years) patients.The long-term outcome of patients (n=855) enrolled in a randomized controlled trial comparing adjuvant chemotherapy with 5-FU alone, 5-FU plus folinic acid (FA), and 5-FU plus interferon-alpha (IFNa) was compared in younger (70 years) and elderly (≥70 years) patients using a quotient of each patient's survival time and his expected residual life expectancy (QSL) and a multivariate Cox proportional hazards model.Eight-year overall survival (OS) rates were 58.3% and 57.4% for younger (n=653) and elderly (n=202) patients, respectively. In elderly patients, 8-year OS rates were 51.4%, 61.8%, and 56.3, and median QSL scores were 0.338, 0.371, and 0.343 for 5-FU (n=59), 5-FU plus FA (n=76), and 5-FU plus IFNa (n=67), respectively. In elderly patients treatment with 5-FU plus FA decreased the risk for an event by 1.5-fold compared to 5-FU (HR=0.657, 95%CI=0.495-0.870, p=0.004) and 5-FU plus INFa (HR=0.685, 95%CI=0.515-0.912, p=0.009).Our analysis clearly demonstrates for the first time an additional benefit of FA for adjuvant treatment of elderly CC patients. We conclude that this regimen is very safe and effective for adjuvant treatment of elderly patients.

The aim of this study was to evaluate a comparison of the coronally advanced flap procedure with or without the use of enamel matrix proteins in the treatment of recession defects.This 2-year study was conducted as a blinded, split-mouth, placebo-controlled, and randomized design. Thirty patients from two dental schools with two paired buccal recession defects were chosen. Surgical recession coverage was performed as the coronally advanced flap technique. One site was additionally treated with derivative (EMD) and the other site with a placebo (propylene glycol alginate [PGA]). A blinded examiner assessed pre- and post-surgical measurements. Measurements comprised the height and width of the gingival recession, height of keratinized tissue, probing attachment level, probing depth, and alveolar bone level.Twenty-four months after therapy, both treatment modalities showed significant root coverage and probing attachment gain. The mean gingival recession decreased from 3.6 to 0.8 mm for the EMD-treated sites and from 3.8 to 1.4 mm for the control sites. However, this difference was not statistically significant (P = 0.122). Similarly, all other clinical parameters did not differ significantly in the between-group comparison except for the recession width (P = 0.027) and probing depth (P = 0.046) exhibiting higher reductions in the EMD group. Complete root coverage could be maintained over 2 years in 53% of the EMD versus merely 23% in the control group. A total of 47% of the treated recessions in the control group deteriorated again in the second year after therapy compared to 22% in the EMD group.Enamel matrix derivative seems to provide better long-term results.

Thymidylate synthase (TS) is a key-enzyme for DNA synthesis and targeted by fluoropyrimidines (FPs). High TS ratios are associated with resistance to systemic FP-based chemotherapy. The aim of this study was to report the influence of TS ratios on primary tumour response to FP-based HAI and long-term follow-up of patients with isolated non-resectable liver tumours in part from a previously published study.Fifty-one consecutive patients with liver tumours receiving HAI with available tumour tissue for TS quantitation were studied between 1991 and 2001. Liver metastases were from colorectal origin in 41 patients and other primary sites in 6 patients. Four patients had primary liver cancers. Tumour tissue was obtained at laparotomy for the intraarterial infusion device implantation. TS mRNA quantitation was performed by RT-PCR using beta-actin as internal standard.The median TS ratio was 2.2 with high variation among tumours ranging from 0.1 to 27. Twenty-two out of 51 patients responded to HAI. The median TS ratio of the responders was 1.6 and more than two-fold lower than the ratio of the non-responders with 3.3 (p0.01). In the subgroup with TSor=3.0, 18 out of 29 patients responded. In the subgroup with TS3.0 only four out of 22 patients responded. No patients with very high TS ratiosor=4.5 ( n = 13) responded to HAI. Median survival was 20 months (range: 3-109). Patients with TS-ratiosor=3.0 showed, with 55%, a higher 2-year survival rate than patients with TS-ratios3.0 with 27%.TS seems to be a predictive and prognostic factor for patients with isolated non-resectable liver tumours receiving FP-based HAI. Patients with very high TS ratios do not seem to benefit from FP-based HAI.

A case-control study of alveolar echinococcosis cases in Germany identifies several risk factors for the disease., We conducted a case-control study to investigate risk factors for acquiring autochthonous alveolar echinococcosis in Germany. Forty cases and 120 controls matched by age and residence were interviewed. Patients were more likely than controls to have owned dogs that killed game (odds ratio [OR] = 18.0), lived in a farmhouse (OR = 6.4), owned dogs that roamed outdoors unattended (OR = 6.1), collected wood (OR = 4.7), been farmers (OR = 4.7), chewed grass (OR = 4.4), lived in a dwelling close to fields (OR = 3.0), gone into forests for vocational reasons (OR = 2.8), grown leaf or root vegetables (OR = 2.5), owned cats that roamed outdoors unattended (OR = 2.3), and eaten unwashed strawberries (OR = 2.2). Sixty-five percent of cases were attributable to farming. Measures that prevent accidental swallowing of possibly contaminated material during farming or adequate deworming of pet animals might reduce the risk for alveolar echinococcosis.

We analyzed survival of patients diagnosed with ampullary cancer (AC) and pancreatic ductal adenocarcinomas (PDAC).Between 1996 and 2009, 505 and 69 patients diagnosed with PDAC and AC, respectively, were identified. Overall survival was analyzed according to tumor entity, therapeutic approach and pathological tumor stage.The 5-year overall survival rate of patients with AC (37%; 95% confidence interval 25-49%) was remarkably higher compared to PDAC patients (7%; 95% confidence interval 5-10%). In both cohorts, surgical resection improved survival. Analysis of pathological factors revealed a survival benefit for patients staged with small primary tumors (pT1/2) and exclusion of distant metastases (M0) for both PDAC and AC. Interestingly, absence of lymph node metastasis substantially improved survival in AC, but not in PDAC.Overall survival of patients with AC is superior compared to that of patients with PDAC. Therapeutically, adequate regional lymph node dissection seems particularly important for the surgical management of AC.

Our aim was to determine predictive factors for the diagnosis and postoperative complications of acute appendicitis.Data sets of 1,439 consecutive adults and children who had an appendectomy between 1999 and 2008 were retrospectively analyzed.A mild acute appendicitis was present in 50 % (n = 722) and a severe acute appendicitis in 25 % (n = 355) of the patients. No signs of any pathology were found in 6 % (n = 82). Gender, white blood count (WBC), C-reactive protein (CRP), and ultrasound (US) examination were important indicators of mild acute and severe acute appendicitis in adults and children. Postoperative complications occurred in 16 % (237/1,439), mainly consisting of wound infections (8 %, n = 122) and bowel dysfunction (5 %, n = 76). Sixty-two patients (4.3 %) required reoperations. One patient died (1/1,439, 0.07 % mortality rate). Age, pathology, and the presence of bacteria in the intraoperative swab were important predictive factors for postoperative complications in adults and children. Time since onset of symptoms and type of operation were also associated with postoperative complications among adults. Complications developed in 21 and 9 % of the adults (155/754 and 10/125) who had open and laparoscopic surgery, respectively.Besides history and clinical examination, WBC, CRP, and US examination remain important factors for diagnosing acute appendicitis. Complications are related to the pathology, presence of bacteria, and type of operation. Early diagnosis within 48 h may be important. A laparoscopic procedure in adults may also cause fewer wound infections.

A medial incision is a common surgical technique to obtain access to the abdomen. Thereby, the muscles involved in movement are manipulated, leading to post-operative restrictions in mobility and pain determined by movement. The aim of this pilot study was to assess the impact of a pre-operative training session using the Viv-Arte model, which is based on kinesthetic mobilisation principles. The parameters to be measured were mobility, pain, and length of hospital stay for patients, who were undergoing elective medial laparotomy. In addition, the study tested the research design and to identify possible effect sizes. The method chosen was a prospective, randomised, controlled, and unblinded design. Twenty-seven patients were involved (median=63 years, 19 of the patients were male) who were to have a medial incision for cystectomy. The intervention involved pre-operative training of post-operative mobility techniques. Mobility was tested using the "Mobilitätstest für Patienten im Akutkrankenhaus (MOTPA) (Mobility test for patients in hospital)"; pain intensity was assessed using the visual analogue scale. The intervention and control groups were comparable for all variables. There were no significant differences in the two groups related to the objectives. It is possible that the study groups or the operationalisation were not appropriate for testing the effects of the intervention. It seems important to continue to develop instruments that are appropriate for measuring the effect of mobility-related interventions.

OBJECTIVE. Extremely preterm infants are at risk for poor growth and impaired neurodevelopment. The objective of this study was to determine whether intrauterine, early neonatal, or postdischarge growth is associated with neurocognitive and motor-developmental outcome in extremely preterm infants. METHODS. Surviving children who were born between July 1996 and June 1999 at RESULTS. A total of 219 (83%) of 263 long-term survivors were evaluated at a median corrected age of 5.4 years. Increasing SD scores for weight and head circumference from birth to discharge were associated with a reduced risk for an abnormal neurologic examination. Catch-up growth of head circumference from birth to discharge was also associated with a reduced risk for impaired mobility. Weight SD score at birth, an increase of weight SD score from birth to discharge, and an increase of head circumference SD score from discharge to follow-up had an effect on the mental processing composite score. The effects of growth on neurodevelopment were by far exceeded by the consequences of intraventricular and periventricular hemorrhage. CONCLUSIONS. Growth from birth to discharge seemed to be associated with long-term motor development. Cognitive development was associated with intrauterine growth measured as weight at birth, early neonatal weight gain, and postdischarge head circumference growth. Improving particularly early neonatal growth may improve long-term outcome in extremely preterm infants, but the effects of improved growth may only be small.

The aim of this study was to investigate an inflammatory response indicated by fibrinogen and plasma viscosity in relation to haemodynamic and clinical findings of patients with stable CHF due to coronary heart disease (CHD).

BACKGROUND. Iron deficiency in early childhood may impair neurodevelopment. In a masked, randomized, controlled trial of early versus late enteral iron supplementation in preterm infants with birth weights of OBJECTIVE. We sought to examine whether early enteral iron supplementation improves neurocognitive and motor development in these infants.METHODS. Children who participated in the above mentioned trial were evaluated by applying the Kaufmann Assessment Battery for Children and the Gross Motor Function Classification Scale at the age of school entry.RESULTS. Of the 204 infants initially randomized, 10 died and 30 were lost to follow-up. A total of 164 (85% of the survivors) were evaluated at a median corrected age of 5.3 years. In this population (n = 164), the mean (±SD) mental processing composite in the early iron group was 92 (±17) versus 89 (±16) in the late iron group. An abnormal neurologic examination was found in 17 of 90 versus 26 of 74, and a Gross Motor Function Classification Scale score of >1 was found in 2 of 90 versus 5 of 74, respectively. Fifty-nine of 90 children in the early iron group were without disability, compared with 40 of 74 in the late iron group. Severe disability was found in 5 of 90 versus 6 of 74 children and 67 of 90 versus 49 of 74 qualified for regular schooling, respectively.CONCLUSIONS. Early enteral iron supplementation showed a trend toward a beneficial effect on long-term neurocognitive and psychomotor development and showed no evidence for any adverse effect. Because the initial study was not designed to evaluate effects on neurocognitive development, the power was insufficient to detect small but potentially clinically relevant improvements. Additional studies are required to confirm the trend towards a better outcome observed in the early iron group.

Elderly persons living in the community are a heterogeneous population. Among them, the screening of persons at risk of falling is still a matter of debate. The aim of this analysis was to improve the identification process of elderly persons living in the community at risk for falling by nursing staff of community- based services. A secondary analysis was performed with the data from a prospective non-randomized interventional trial. The study included 268 community-dwelling older adults (mean age of 82 years, 81.3% female) from Ulm and Neu-Ulm with a followup period of 12 months. Fall risk indicators were extracted from the nursing assessment and analysis with crude odds ratios revealed the following risk indicators for falls: assistance when transferring, bathing and climbing a flight of stairs as well as fall history. Afterwards, fall risk indicators were selected by backward elimination in a multiple logistic regression. Variable selection identified a positive fall history and the need for assistance when bathing as important risk indicators. These two risk indicators could be used as a screening tool, which would be easy to perform by nursing staff in their daily work. This screening test defined as more than one fall in the last 12 months or bathing assistance, the first ADL to be affected in the disablement process, has a sensitivity of 85.3% and a specificity of 42.1%.

Despite adjuvant 5-fluorouracil (5-FU) therapy, approximately 30% of patients with International Union against Cancer stage II and III colorectal cancer develop recurrence. In this study, we determined the prognostic value of thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD) expression in colorectal cancer patients treated with adjuvant 5-FU.A real-time reverse transcription-PCR technique for quantitation of relative gene expression from paraffin-embedded specimen was established first. In a second step, archival paraffin-embedded primary tumor tissue of 309 patients who participated in adjuvant colorectal cancer trials was analyzed for TS and DPD mRNA expression.TS mRNA expression determined by real-time reverse transcription-PCR correlated with TS protein levels determined by TS immunoblot and immunohistochemistry in cultured colon cancer cell lines and paraffin-embedded primary tumor tissue. TS mRNA levels in fresh-frozen tissues also correlated with TS mRNA levels in corresponding paraffin sections. Among the patients receiving adjuvant 5-FU therapy, those with high TS survived longer than those with low TS, and in each TS subgroup, the ones with low DPD survived longer than the ones with high DPD levels. Multiple Cox regression analysis showed that besides tumor stage (P = 0.010), only the combination of TS and DPD expression turned out to be an independent prognostic factor for survival (P = 0.030).This suggests that TS and DPD quantitation may be helpful to evaluate prognosis of patients receiving adjuvant 5-FU and that patients with high TS and low DPD may benefit from adjuvant 5-FU chemotherapy.

To determine the long-term neurodevelopmental outcome in extremely preterm infants after offering life support to all infantsor = 23 weeks gestation ("pro-active management").With parental consent, all infants born at 23 to 25 completed weeks gestation were treated proactively. Surviving infants born from July 1996 to June 1999 were assessed for standardized cognitive and neurological outcomes at 5 years corrected age.70 of 91 infants admitted to the neonatal intensive care unit survived until follow-up. 67 of the 70 surviving infants were examined at a median corrected age of 5.6 years; 12% had cerebral palsy and a Gross Motor Function Classification Scale score2; 4% were blind; 1% required a hearing aid; and 12% had a Kaufmann Assessment Battery for Children mental processing composite51, resulting in 18% sustaining a severe disability. 43% had normal results on a neurological examination, Gross Motor Function Classification Scale score = 0, mental processing composite85, and had neither severe visual nor hearing impairment. 57% qualified for regular schooling.Improved survival was not associated with an increased risk of severe disability when compared with results of earlier publications. These findings may result from proactive management and are important for counseling patients at risk of imminent extremely preterm delivery.