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Introduction: Compared to abdominoperineal resection (APR), sphincter preservation using low anterior resection (AR) for rectal cancer (RC) implies the risk of impaired functional outcome and postoperative complications associated with a persistent or additionally required ostomy. The aim of our study was to compare quality of life (QoL) after AR and APR with a special separate analysis of AR patients with a stoma. Methods: QoL of 84 APR, 356 AR, and 29 AR patients with complications and an additional stoma, termed converted therapy (COT) patients, was compared with regard to groups and effect of radiotherapy (RT). All patients received rectal resection between 1998 and 2013, and 47% of the patients had RT. QoL was assessed using extended EORTC QLQ-C30 and -CR38 questionnaires. Results: Questionnaires from 57 APR, 165 AR, and 25 COT patients alive were evaluated after a median time of 4 years after surgery. Global health status was equally high in AR and APR patients (score: 67), whereas COT patients turned out with a significantly lower score of 50 (p = 0.007). Compared to APR and COT, AR patients revealed less symptoms and higher functionality, especially for physical, role, and social functioning (p < 0.001). The reduction of QoL instances was significant in the COT group and in all patients treated by RT. Conclusion: QoL after RC resection may be further improved by avoiding additionally required ostomy after AR but also RT by a better individual selection of qualified patients. Qualification parameters urgently need to be defined by prospective studies.

Rarely, scientific developments centered around the patient as a whole are published. Our multidisciplinary group, headed by gastrointestinal surgeons, applied this research philosophy considering the most important aspects of the diseases “colon- and rectal cancer” in the long-term developments. Good expert cooperation/knowledge at the Comprehensive Cancer Center Ulm (CCCU) were applied in several phase III trials for multimodal treatments of primary tumors (MMT) and metastatic diseases (involving nearly 2000 patients and 64 centers), for treatment individualization of MMT and of metastatic disease, for psycho-oncology/quality of life involving the patients’ wishes, and for disease prevention. Most of the targets initially were heavily rejected/discussed in the scientific communities, but now have become standards in treatments and national guidelines or are topics in modern translational research protocols involving molecular biology for e.g., “patient centered individualized treatment”. In this context we also describe the paths we had to tread in order to realize our new goals, which at the end were highly beneficial for the patients from many points of view. This description is also important for students and young researchers who, with an actual view on our recent developments, might want to know how medical progress was achieved.

BACKGROUND To cope with the COVID-19 outbreak in Germany, the government imposed a lockdown, which led to restrictions and lifestyle changes for the population. PURPOSE This study aimed to evaluate the impact of the lockdown on activities causing trauma and the consultation in emergency rooms. MATERIAL AND METHODS All consecutive trauma patients consulting the Emergency Department of the Marienhospital Stuttgart (MHS), Germany, during the 6 weeks preceding the lockdown, during and after the lockdown were included. The time and type of consultation, treatment received, Manchester triage score, type of trauma, the anatomical region of the injury as well as demographic data were reported and compared. RESULTS The study included 551 cases during lockdown, 943 cases before and 783 cases after the lockdown. We observed a reduced caseload during the lockdown of 41.6% compared to before and of 29.7% compared to after (p

To cope with the COVID-19 outbreak in Germany, the government imposed a lockdown, which led to restrictions and lifestyle changes for the population.This study aimed to evaluate the impact of the lockdown on activities causing trauma and the consultation in emergency rooms.All consecutive trauma patients consulting the Emergency Department of the Marienhospital Stuttgart (MHS), Germany, during the 6 weeks preceding the lockdown, during and after the lockdown were included. The time and type of consultation, treatment received, Manchester triage score, type of trauma, the anatomical region of the injury as well as demographic data were reported and compared.The study included 551 cases during lockdown, 943 cases before and 783 cases after the lockdown. We observed a reduced caseload during the lockdown of 41.6% compared to before and of 29.7% compared to after (p 0.001). Patients were on average older in the observation group than in both control groups (before : 51.5 years, lockdown: 56.1 years, after: 51.6 years) (p 0.001). Injuries to the head and neck were constant (25.0%, 25.4%, 25.5%). We noticed lower limb injuries decreasing (26.1%, 22.3%, 22.7%) and upper limb injuries increasing (25.5%, 31.8%, 30.1%). A decrease in sports injuries (11.1%, 5.1%, 9.1%) and work accidents (16.1%, 10.7%, 12.8%) resulted in more domestic accidents (30.4%, 52.5%, 31.8%). Self-referral decreased (67.7%, 53.2%, 60.3%) while referral via paramedics increased (28.3%, 38.7%, 35.6). Blunt trauma was the most common cause of injury (55.6%, 61.0%, 55.3%). Indications for surgery were higher (16.8%, 21.6%, 14.0%).The lockdown and restrictions in personal life and daily routine had an impact on the frequency, etiology and management of trauma patients in Stuttgart.HINTERGRUND: Zur Eindämmung des COVID-19-Ausbruchs erließ die Bundesregierung einige Regeln und Einschränkungen für die Bürger. ZIEL: Diese Studie widmet sich dem Einfluss der Maßnahmen auf traumatologische Vorstellungen in der Notaufnahme.Alle konsekutiven traumatologischen Patienten der Notaufnahme des Marienhospitals Stuttgart (MHS), die sich in den 6 Wochen jeweils vor und nach dem Lockdown sowie währenddessen vorstellten, wurden einbezogen. Die Zeit und Art der Vorstellung, die Behandlungsart, der Manchester Triage Score, die Region und Art der Verletzung sowie demografische Daten wurden ermittelt und verglichen.Es wurden 551 Fälle während des Lockdowns, 943 Fälle davor und 783 Fälle danach eingeschlossen. Es konnte eine Fallzahlreduktion um 41,6 % im Vergleich zu davor und um 29,7 % verglichen mit danach (p 0,001) beobachtet werden. Während des Lockdowns waren die Patienten im Mittel älter (vorher: 51,5 Jahre, Lockdown: 56,1 Jahre, danach: 51,6 Jahre) (p 0,001). Kopf-Hals-Verletzungen waren konstant (25,0 %, 25,4 %, 25,5 %). Verletzungen der unteren Extremität waren seltener (26,1 %, 22,3 %, 22,7 %), der oberen Extremität häufiger (25,5 %, 31,8 %, 30,1 %). Besonders Sportverletzungen (11,1 %, 5,1 %, 9,1 %) und Arbeitsunfälle (16,1 %, 10,7 %, 12,8 %) reduzierten sich, dafür stiegen häusliche Unfälle (30,4 %, 52,5 %, 31,8 %). Selbsteinweisungen gingen zurück (67,7 %, 53,2 %, 60,3 %), Vorstellungen mittels Rettungsdienst stiegen (28,3 %, 38,7 %, 35,6 %). Stumpfes Trauma war der häufigste Grund einer Vorstellung (55,6 %, 61,0 %, 55,3 %). Es musste öfter operiert werden (16,8 %, 21,6 %, 14,0 %).Der Lockdown und die Einschränkungen hatten einen Einfluss auf Zahl sowie Art und Behandlung von Traumapatienten in Stuttgart.

Zusammenfassung Hintergrund 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. Methoden 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. Zervixlänge3 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. Ergebnis 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. Schlussfolgerung 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 Frühgeborenen

Background: There is still the need to optimize adjuvant treatment of colon cancer (CC). Standard adjuvant chemotherapy using 5-fluorouracil (FU) and folinic acid (FA) was compared with a combination including irinotecan (Folfiri). The aim of the present report was to analyze overall survival (OS) after long-term follow-up, to summarize final recurrence rates and toxicity data, and to identify possible clinical and pathological factors associated with prognosis. Methods: Patients (CC stage IIb and III) were randomized to a 6-month treatment with FUFA or Folfiri. The trial was closed after 275 of 588 planned patients, 269 of which were included in the intention-to-treat analysis. Results: 133 and 136 patients received FUFA and Folfiri, respectively. Adjuvant therapy was not completed for 16 FUFA (12.0%) and 44 Folfiri (32.4%) patients. Toxicities grade III and IV were observed in 17 (12.8%) patients treated with FUFA and in 50 (36.8%) patients treated with Folfiri. Recurrences occurred in 46 of 133 (34.6%) and in 47 of 136 (34.6%) patients who received FUFA and Folfiri, respectively. 5-year OS rates were 69.9% (95% confidence interval (CI): 61.2-77.1) for FUFA and 72.7% (95% CI: 63.9-79.8) for Folfiri. OS was associated with tumor grading (1 & 2 vs. 3), tumor sub-stage (II vs. IIIa vs. IIIb vs. IIIc), and tumor location (left vs. right colon). Conclusion: Folfiri cannot be generally recommended for adjuvant chemotherapy of CC. Besides tumor grading and sub-staging, prognosis of CC may depend on tumor location. Left-sided tumors had a significantly better prognosis irrespective of treatment.

Colorectal cancer (CRC) is the third most common cancer worldwide. A diagnosis at early stages with enhanced screening methods is vital as metastases and recurrences increase mortality. The aim of this study was to analyze the tumor markers CEA and CA19-9 combined in correlation with diagnostics and prognosis. Therefore, 1487 patients with CRC who were diagnosed and treated between 2000 and 2015 at the University Hospital Ulm, Germany, were retrospectively evaluated. Overall and recurrence-free survival was analyzed in association with preoperative CEA and CA19-9 separately and combined and a multivariate analysis was performed. The 5-year overall survival was significantly shorter in patients with a CEA or CA19-9 level ≥200 compared to patients with an increased, but &lt, 200, or normal level (CEA: 69%/44%/7%, CA19-9: 66%/38%/8%). Patients with both tumor markers increased also showed a remarkably shorter 5-year survival rate (CEA+/CA19-9+: 23%). The multivariate analysis emphasizes these results (p-value &lt, 0.0001). Patients with both tumor markers elevated had the shortest 5-year recurrence-free survival rate, followed by patients with either CEA or CA19-9 elevated (CEA-/CA19-9-: 79%, CEA+/CA19-9, CEA-/CA19-9+: 65%, CEA+/CA19-9+: 44%). In conclusion, measuring CEA and CA19-9 preoperatively in CRC patients is reasonable and could be useful as a prognostic factor.

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.

Frühgeburtenrate in 6 Perinatalzentren in Baden-Württemberg – Potential zur Reduktion der Frühgeborenenzahl Sehr geehrte Herren Rossi, Heller und Maier,vielen Dank für Ihren Leserbrief bezüglich unserer Arbeit Trotter et al. 1, gerne gehen wir auf die einzelnen Punkte ein.

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.

BACKGROUND Since 2006 an assessment of the neurodevelopmental outcome of very low birth weight infants (VLBWI) at a corrected age of 2 years is mandatory for every perinatal centre in Germany. The aim of our study was to check how complete these assessments were performed in our population of infants born at our perinatal centre and receiving treatment within our local neonatal network. Furthermore, the data obtained will be used for prenatal consultations. Another objective was to identify risk factors for adverse neurodevelopmental outcomes. METHODS All VLBWI were invited for a follow-up exam using the Bayley Scales of Infant Development II (BSID-II) or III (BSID-III), or Griffiths Mental Developmental Scales) at 2 years corrected age. The results of children assessed by other institutions were collected. RESULTS 142 (69.3%) of the 205 VLBWI, born and finally discharged alive at the perinatal centre in Ulm were assessed at a median (minimum - maximum) corrected age of 23 (18-27) months. The BSID-II Psychomotor Development Index (PDI) 91 was (< 50-128) (n=115), the BSID-II Mental Development Index (MDI) was 87 (< 50-134) (n=96), BSID-III MDI 95 (60-112) (n=29) and the Griffiths Score was 93 (67-140) (n=17). Severe disability was diagnosed in 36 (25.4%) of the children studied. Gestational age and higher grade intraventricular haemorrhage were associated independently with severe disability. CONCLUSIONS It is very difficult to achieve a high rate of follow-up examinations in preterm infants

Die mediane Laparotomie (Mittelschnitt) stellt einen häufig genutzten Standardzugang zum Abdomen in der Chirurgie dar. Dabei werden für die Bewegung notwendige Muskeln manipuliert und es kommt postoperativ zu Einschränkungen der funktionalen Mobilität und zu bewegungsabhängigen Schmerzen. Ziel der Pilotstudie war es, die Auswirkungen eines präoperativen Bewegungsschulungsprogramms nach dem Viv-Arte-Lernmodell für kinästhetische Mobilisation auf Mobilität, Schmerzen und Verweildauer bei Patienten mit elektiver medianer Laparotomie zu testen, das Studiendesign zu überprüfen und mögliche Effektstärken zu ermitteln. Es wurde eine prospektive, randomisierte, kontrollierte und unverblindete Studie durchgeführt. Eingeschlossen wurden 27 Patienten (Median = 63 Jahre, 19 männlich) mit medianer Laparotomie bei Zystektomie. Die Intervention beinhaltet die präoperative Schulung für das postoperative Mobilisationsverhalten. Die Mobilität wurde mithilfe des Mobilitätstests für Patienten im Akutkrankenhaus (MOTPA) gemessen, die Schmerzintensität mittels einer visuellen Analog-Skala (VAS). Interventions- und Kontrollgruppe waren hinsichtlich der Kontrollvariablen vergleichbar. Es gab keine aussagekräftigen Gruppenunterschiede hinsichtlich der Zielkriterien. Möglicherweise sind die gewählten Zielgrößen bzw. ihre Operationalisierung ungeeignet, um Effekte der Intervention aufzuzeigen. Es erscheint notwendig, weiter an der Entwicklung von Instrumenten zu arbeiten, die geeignet sind, die Wirkung bewegungsbezogener Interventionen zu messen.

Adjuvant chemotherapy is recommended for stage III colon cancer. The aim of this study was to identify important prognostic factors among patients with colon cancer receiving adjuvant 5-FU-based treatment.Data sets of 855 colon cancer patients treated between 1992 and 1999 within a multicenter adjuvant trial comparing 5-FU modulation with folinic acid or interfereron-alpha were examined. Backward elimination in a proportional hazards model was used to identify prognostically relevant clinical and pathological factors.Tumor recurrence (p0.001), duration of adjuvant treatment (p0.001), tumor substage (p=0.004), age (p=0.005), grading (p=0.016), treatment-related toxicity (p=0.021), and treatment (p=0.031) were identified in descending order of importance as prognostic factors for overall survival.Adjuvant 5-FU-based treatment should be performed for at least 6months with a stepwise adjustment of 5-FU doses until toxicityWHO II. Substages should be reported separately and used for stratification in future trials due to their broad variation in outcome. In the future, this may result in adjuvant treatment of stage III colon cancer adjusted for the risk of substages.

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.

Gegenwartig existieren lediglich Beobachtungsstudien und Expertenmeinungen, die den Umgang von bewegungseinschrankenden Masnahmen begrunden. Demgegenuber steht eine sehr unterschiedliche Praxis in der Langzeitpflege und den akutmedizinischen Institutionen. Etwa 3–5% der Heimbewohner werden durchschnittlich korpernah fixiert. Es existieren grose regionale Unterschiede. Die Huftfrakturrate betragt bei Heimbewohnern etwa 50 pro 1000 Bewohnerjahre. Ungefahr 40–50% der Heimbewohner werden mit potenziell bewegungseinschrankenden Psychopharmaka behandelt. Zur Untersuchung der Effektivitat einer Intervention zur Reduktion von bewegungseinschrankenden Masnahmen (BEM) bei Heimbewohnern mit kognitiven Einschrankungen wurde eine cluster-randomisierte Studie geplant. Die Intervention umfasst die Verbesserung des Wissens im Umgang mit BEM und den Einsatz von technischen Hilfen zur Reduktion von sturzbedingten Verletzungen. Die Studienpopulation umfasst mindestens 200 Bewohner in 54 Pflegeeinrichtungen in drei Bundeslandern. Es wird eine 50% Reduktion der Fixierungszahlen angestrebt. Das Studiendesign sieht eine Wartelisten-Kontroll-Intervention vor. Primare Endpunkte sind die Zahl der fixierten Personen und die Zeiten (Stunden) der Anwendungen von BEM. Der Einsatz von Psychopharmaka, Sturze und Verletzungen sowie neufixierte Personen werden ebenfalls dokumentiert. Die Studie umfasst eine gemeinsame dreimonatige Dokumentationsphase und eine vierteljahrige Intervention. Mit der Untersuchung wird angestrebt, ein in die Praxis umsetzbares und kontrollierbares Modell zu testen.

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.

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.

Objectives. To examine whether early enteral iron supplementation (EI) would improve serum ferritin as a measure of nutritional iron status at 2 months of age and would prevent definite iron deficiency (ID) in infants with a birth weight of Methods. Infants were randomly assigned to receive enteral iron supplementation of 2 to 6 mg/kg/day as soon as enteral feedings of >100 mL/kg/day were tolerated (EI) or at 61 days of life (late enteral iron supplementation [LI]). Nutritional iron status was assessed: 1) at birth, 2) at 61 days of life, 3) when the infants reached a weight of 1.6 times birth weight, and 4) before blood was transfused at a hematocrit of 50% one week after the onset of enteral iron supplementation. Restrictive red cell transfusion guidelines were followed and all transfusions were documented. Erythropoietin was not administered. The primary outcome variables were: 1) ferritin at 61 days and 2) the number of infants with ID. Results. Ferritin at 61 days was not different between the groups. Infants in the LI group were more often iron-deficient (26/65 vs 10/68) and received more blood transfusions after day 14 of life. No adverse effects of EI were noted. Conclusions. EI is feasible and probably safe in infants with birth weight

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.

The objective of the study was to establish guidelines for the application of fine-wire or needle electrodes in the semispinalis cervicis and semispinalis capitis muscles. First of all, measured data for the puncture angle and puncture depth of each muscle were determined in CT scans. Using a regression approach, a model relation of these data with the neck circumference was established. This made it possible to accurately determine the puncture angle and puncture depth on the basis of the known neck circumference. In a further step, the neck muscles of seven human cadavers were punctured with wires in order to check the workability of these guidelines. At the same time, the wires’ positions in relation to important structures (nerves, vessels) were studied. Both muscles can be punctured with a high degree of reliability. However, when puncturing the semispinalis cervicis muscle, one has to pass through a layer that contains vessels, nevertheless the risk of injury is regarded as very small. The technique enables intramuscular EMG measurements of the two muscles in manifold clinical problems.

We refer to our earlier publication in this journal [1] in which we – in agreement with the results obtained by many other investigators – reported a short-term beneficial effect of pars plana vitrectomy (PPV) on the morphological and functional characteristics of eyes with diabetic macular edema. Since the duration of a Received: August 14, 2007 Accepted after revision: April 11, 2008 Published online: April 22, 2009

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.

3608 Background: In this phase III trial (FOGT-2) we studied whether one of the 5-FU modulations with either folinic acid (FA) or Interferon alpha-2a (IFNa) increased overall survival compared to the standard treatment in R0-resected rectal cancer, 5-fluorouracil (5-FU) plus levamisole (LEV) for 12 months, plus postoperative radiotherapy (RT). Methods: From 7/92 to 5/03 793 patients with resected rectal cancer stages UICC II (267 pts.) and UICC III (526 pts.) were randomized into three arms and stratified (N-stage, centers). After a postoperative loading course with 5-FU [450mg/ m2 d1–5 (arms A and C)] or 5-FU [450mg/m2 plus folinic acid (Rescuvolin, medac, Hamburg, Germany), 200 mg/ m2 d1–5 (arm B)], LEV was administered orally at 150 mg/d d1–3, q every 2 weeks. 4wks later treatment was continued weekly for up to 52 wks. RT was given over a 6-wks postoperative period in a 3-field technique up to a dose of 45–50,4 Gy in 1,8 Gy fractions 5x/wk with a 20% dose reduction of 5-FU. Arm A (280 pts.) was treated...