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PubMed2003

The treatment of elderly patients with high-grade gliomas.

Elderly patients with cancer are frequently excluded from cancer therapy trials, treated suboptimally, or not treated at all because of the widely held belief that elderly patients do not tolerate chemotherapy and/or radiotherapy (RT) as well as younger patients. Excluding elderly patients from conventional treatment, chemotherapy in particular, is often based on ad hoc decisions rather than on sound scientific data. Malignant gliomas are the most common primary brain tumors in adults, and the age-adjusted incidence of high-grade gliomas has increased over recent years, especially in the elderly. However, few investigators focus on the treatment of high-grade gliomas in the elderly. Data from retrospective studies and meta-analyses suggest that elderly patients with high-grade gliomas have a poorer outcome than younger patients, possibly because of the presence of comorbidity, resistance to cancer therapy, genetic aberrations, different histology, neurodegeneration, or age discrimination. The optimal treatment of elderly patients with high-grade gliomas has not been determined. Surgical debulking and postoperative RT are associated with a significant increase in survival among elderly patients who are in good clinical condition. A recent report has shown that treatment with temozolomide (Temodar [US], Temodal [international]; Schering-Plough Corporation, Kenilworth, NJ) plus RT provides a significant survival benefit compared with RT alone and a significantly improved time to progression compared with RT plus standard chemotherapy (lomustine, procarbazine, and vincristine). Further, temozolomide was well tolerated in the elderly patient population and was less toxic than standard chemotherapy. Therefore, it could be recommended that a full course of RT be followed by adjuvant temozolomide in elderly patients with good prognostic factors. Further, temozolomide alone could be considered as a treatment option for elderly patients with glioblastoma with poorer performance status and for patients who cannot tolerate RT. Results from larger prospective trials will determine the optimal role of chemotherapy, particularly temozolomide, in elderly patients with malignant gliomas.

Age Factors↗
PubMed2003

Position of the American Dietetic Association and Dietitians of Canada: Vegetarian diets.

It is the position of the American Dietetic Association and Dietitians of Canada that appropriately planned vegetarian diets are healthful, nutritionally adequate, and provide health benefits in the prevention and treatment of certain diseases. Approximately 2.5% of adults in the United States and 4% of adults in Canada follow vegetarian diets. A vegetarian diet is defined as one that does not include meat, fish, or fowl. Interest in vegetarianism appears to be increasing, with many restaurants and college foodservices offering vegetarian meals routinely. Substantial growth in sales of foods attractive to vegetarians has occurred, and these foods appear in many supermarkets. This position paper reviews the current scientific data related to key nutrients for vegetarians, including protein, iron, zinc, calcium, vitamin D, riboflavin, vitamin B-12, vitamin A, n-3 fatty acids, and iodine. A vegetarian, including vegan, diet can meet current recommendations for all of these nutrients. In some cases, use of fortified foods or supplements can be helpful in meeting recommendations for individual nutrients. Well-planned vegan and other types of vegetarian diets are appropriate for all stages of the life cycle, including during pregnancy, lactation, infancy, childhood, and adolescence. Vegetarian diets offer a number of nutritional benefits, including lower levels of saturated fat, cholesterol, and animal protein as well as higher levels of carbohydrates, fiber, magnesium, potassium, folate, and antioxidants such as vitamins C and E and phytochemicals. Vegetarians have been reported to have lower body mass indices than nonvegetarians, as well as lower rates of death from ischemic heart disease; vegetarians also show lower blood cholesterol levels; lower blood pressure; and lower rates of hypertension, type 2 diabetes, and prostate and colon cancer. Although a number of federally funded and institutional feeding programs can accommodate vegetarians, few have foods suitable for vegans at this time. Because of the variability of dietary practices among vegetarians, individual assessment of dietary intakes of vegetarians is required. Dietetics professionals have a responsibility to support and encourage those who express an interest in consuming a vegetarian diet. They can play key roles in educating vegetarian clients about food sources of specific nutrients, food purchase and preparation, and any dietary modifications that may be necessary to meet individual needs. Menu planning for vegetarians can be simplified by use of a food guide that specifies food groups and serving sizes.

Adolescent↗
PubMed2002

The impact of human herpesvirus-6 and -7 infection on the outcome of liver transplantation.

Human herpesvirus (HHV)-6 and -7 are novel members of the beta-herpesvirus family that maintain latency in the human host after primary infection. Reactivation from latency and/or increased degree of viral replication occurs during periods of immune dysfunction. The clinical effect of HHV-6 and HHV-7 reactivation in recipients of liver transplants is now being recognized. Clinical illnesses such as fever, rash, pneumonitis, encephalitis, hepatitis, and myelosuppression have been described in a number of anecdotal reports. Moreover, a growing body of evidence suggests that the more important effect of HHV-6 and HHV-7 reactivation on the outcomes of liver transplantation may be mediated indirectly by their interactions with the other beta-herpesvirus-cytomegalovirus (CMV). Coinfection among these three beta-herpesviruses in clinical syndromes that were classically ascribed to be solely caused by CMV has been shown and has raised substantial interest in the potential role of HHV-6 and HHV-7 as copathogens in the direct and indirect illnesses caused by CMV. This article reviews the current scientific data on the role and the magnitude of impact of HHV-6 and HHV-7 infection on the outcomes of liver transplantation.

Herpesvirus 6, Human↗
PubMed2002

Artificial nutrition: dilemmas in decision-making.

Artificial nutrition is a supportive medical therapy to attain pre-defined objectives, which should be adjusted to changing clinical situations. Optimal decision-making is based on the available scientific evidence blended with the science of probability and a spice of the art of uncertainty. Complex dilemmas in decision-making often occur given the paucity of solid scientific data to endorse precise indications and timing of prescription, whilst goals to be achieved may vary from clinical benefits to compassionate use. Hence, healthcare professionals must be aware and abide by the current norms of medical ethics, whereby eliciting and respecting patients' preferences is paramount. Patient-focused care implies: to respect patients' rights, to clearly inform and involve the patient in the decision-making process, to implement a therapeutic plan based on the best available care to suit patients' needs and informed options.

Decision Making↗
PubMed2000

[Initiation of rehabilitation after surgery for herniated lumbar disk: pilot study of efficacy from the viewpoint of the surgical hospital].

The initiation of rehabilitation after lumbar disc surgery in Germany is up to the operating hospital. A decision between outpatient and inpatient rehabilitation is possible. Until now this decision is not based on scientific data but on the individual experience of the hospital. This prospective study compares the effect of outpatient and inpatient therapy: In 65 patients medical and psychosocial data were collected shortly before operation, 1 week and 6 months after surgery. Of these patients, 42 underwent inpatient, 21 outpatient rehabilitation, 2 patients renounced rehabilitation. The outpatient and inpatient rehabilitation groups showed no significant difference in testing before or shortly after the operation concerning subjective state of health and somatic findings. Some 6 months later, long term outcome was identical, i.e. the groups did not differ in psychosocial or medical respects. However, the inpatient rehabilitation group had taken significantly longer to return to work. This pilot study stresses the importance of further research on rehabilitation after lumbar disc surgery. It should be shared by surgeons and rehabilitation experts.

Adult↗
PubMed2001

Outcome measures and treatment endpoints other than platelet count in childhood idiopathic thrombocytopenic purpura.

Therapy for children with acute idiopathic thrombocytopenic purpura (ITP) has been controversial, in great part because it is not evidence based. Some physicians are activists, treaters, or interventionists with regard to therapy of ITP whereas others have been described as nontreaters or noninterventionists. Platelet count (which is often extremely low in ITP) has generally been employed as a surrogate measure of hemorrhagic risk even though life-threatening or fatal bleeding is rare. Virtually all of the randomized clinical trials conducted in childhood ITP have focused on platelet counts as the sole outcome measure. However, other determinants should influence clinical decision making, including assessment of bleeding tendency. Laboratory testing has not been helpful in this regard, but clinical assessment by means of semiquantitative bleeding scores may prove more useful than simply designating a patient as having a "dry" or "wet" purpura. The side effects as well as costs (direct and indirect) of therapy must also be considered when attempting to weigh the merits of drug therapy against their risks. Finally, the effect of ITP and its treatment on health-related quality of life should be determined. Measurement tools to assess each of these alternative outcome measures are in early stages of development. Employing them in addition to platelet counts in future clinical trials will allow treatment to be based more on scientific data than treatment philosophy.

Adolescent↗
PubMed2001

[Current challenges on hospital hygiene].

Although microorganisms are the main cause of nosocomial infections, they are by no means their only determinants. Patient-associated factors play a major role (especially immune status), the therapeutic conditions (personnel behaviour, 'devices') and the patient's environment. The hospital infection control team is responsible for implementing and operating an efficient and cost-effective infection control and prevention system. Scientific data must be evaluated and every effort made to continuously improve recommendations. In order to implement an efficient and cost-effective infection control and prevention system, the infection control team must formulate sound, evidence-based recommendations and question established 'rituals'. Inappropriate measures, e. g. the routine disinfection of floors in wards and hallways place a burden on staff, patients and the environment, and distract staff from other critical measures such as proper hand hygiene. Nosocomial pneumonia, urinary tract infections, surgical wound infections and catheter-associated sepsis are the commonest hospital-acquired infections, and Intensive Care Units have become the foci of antibiotic resistance. Although the antimicrobial resistance situation is better in Germany than in other countries, e. g. Eastern and Southern European countries and the USA, substantial regional differences exist. The increase in methicillin (oxacillin) resistant S. aureus (MRSA) is particularly worrying. Building up an effective surveillance system for nosocomial infections, as demanded by the new German infection control act has far-reaching implications and entails recording risk-adjusted infection rates (KISS project = Hospital Infection Surveillance System of the National Reference Center for Hospital Hygiene in cooperation with the Robert Koch-institute). Proper collaboration between hospital staff in implementing infection control measures, and especially hand hygiene is of paramount importance.

Communicable Disease Control↗
PubMed2002

[Citation rates of medical German-language journals in English-language papers - do they correlate with the Impact Factor, and who cites?].

BACKGROUND AND OBJECTIVE: Several publications are warning that the German language is no longer needed for transmission of scientific data. One of the causes may be the Impact Factor (IF), which appears to be derived predominantly from Anglo-American journals. The aim of this study was to check actual international attention paid to German-language journals, i. e. their citation frequencies in English-language papers. Are these citing rates in English-language articles correlated to the IF, and from where do citing articles originate? METHODS: Of 25 arbitrarily selected >85 % German-language medical journals, IF as well as language distributions of citing articles were determined by searching publication years 1995 - 2000 in Science Citation Index (SCI). MEDLINE and EMBASE were used as supplementary retrieval systems. RESULTS: (i) The sample journals displayed an average IF = 0.357. A 99 % correlation (Pearson factor r = 0.987; n = 25) was observed between our >> constructed<< IF 2000 and IF published in Journal Citation Report 2000. This proves Stegmann's IF determination method to be valid. On the average, 53 % German-language and 45 % English-language articles between 1995 - 2000 cited the 1995 - 1999' contributions of the studied journals. No correlation was observed between IF vs. rates of citing articles in English (r <0.1). 64 % of citing English-language articles showed corporate sources in Germany/ Austria/ Switzerland, and 13.5 % authors' institutions in USA. CONCLUSIONS: (i) An IF >/=1 is, obviously, very hard to attain by German-language journals. ISI's differentiation between Citing vs. Cited-only Journals (the latter often serving as MEDLINE/ EMBASE sources) during derivation of IF appears unjustified. (ii) English now serves as the predominant communication language in sciences in German-speaking countries, but has not supplanted the German language. Our study reveals remarkable international attention rates remaining.

Bibliometrics↗
PubMedDate not supplied

[Citation rates of medical German-language journals in English-language papers--do they correlate with the impact factor, and who cites? (reprint)].

BACKGROUND AND OBJECTIVE: Several publications are warning that the German language is no longer needed for transmission of scientific data. One of the causes may be the Impact Factor (IF), which appears to be derived predominantly from Anglo-American journals. The aim of this study was to check actual international attention paid to German-language journals, i. e. their citation frequencies in English-language papers. Are these citing rates in English-language articles correlated to the IF, and from where do citing articles originate? METHODS: Of 25 arbitrarily selected > 85 % German-language medical journals, IF as well as language distributions of citing articles were determined by searching publication years 1995 - 2000 in Science Citation Index (SCI). MEDLINE and EMBASE were used as supplementary retrieval systems. RESULTS: (i) The sample journals displayed an average IF = 0.357. A 99 % correlation (Pearson factor r = 0.987; n = 25) was observed between our "constructed" IF 2000 and IF published in Journal Citation Report 2000. This proves Stegmann's IF determination method to be valid. On the average, 53 % German-language and 45 % English-language articles between 1995 - 2000 cited the 1995 - 1999' contributions of the studied journals. No correlation was observed between IF vs. rates of citing articles in English (r < 0.1). 64 % of citing English-language articles showed corporate sources in Germany/Austria/Switzerland, and 13.5 % authors' institutions in USA. CONCLUSIONS: (i) An IF >/= 1 is, obviously, very hard to attain by German-language journals. ISI's differentiation between Citing vs. Cited-only Journals (the latter often serving as MEDLINE/EMBASE sources) during derivation of IF appears unjustified. (ii) English now serves as the predominant communication language in sciences in German-speaking countries, but has not supplanted the German language. Our study reveals remarkable international attention rates remaining.

English Abstract↗
PubMed2003

In utero cocaine exposure: a thorny mix of science and mythology.

Fetal cocaine exposure has proven to be an area of medicine that has generated more heat than light. Although many reports associate cocaine with a variety of isolated structural anomalies, there is no detectable syndromic clustering, raising doubts about a real causal association or a specific teratogenic action. Potential confounding variables, including the abuse of other drugs, pregnancy deprivations, and socially patterned maternal behaviors, have limited the reliability of observational studies, making it difficult to demonstrate effects solely attributable to cocaine. The clinical expression of in utero cocaine exposure is contextual, critically dependent on the biology/environment interplay. The present work summarizes the fetal structural anomalies that have been associated in the literature with cocaine use during pregnancy, and reviews the putative mechanisms of fetal impairment secondary to cocaine exposure. The final discussion of methodologic issues in cocaine epidemiology highlights the need for innovative approaches to assure that the myths conjured up about "crack babies" are replaced with reliable, high-quality scientific data.

Abnormalities, Drug-Induced↗
PubMed2003

Physical and physiological factors associated with success in professional alpine skiing.

Scientific data on the physiological profile of world class skiers are sparse. During the last decade the Austria Ski Team was the most successful in the world. It was the objective of this study to describe the physical and physiological characteristics of World Cup (WC) skiers. Twenty female and 28 male members of the Austrian WC Ski Team were examined pre- and post-seasonally from 1997 to 2000. Physical parameters such as age, height, body mass, body mass index, percent body fat and thigh circumference were recorded from each athlete. The physiological variables investigated consisted in the aerobic power and in the muscle strength of the lower limbs. Racing performance was defined by the WC ranking position. The athlete's aerobic performance capacity was assessed by maximal exercise testing on a bicycle ergometer, and the isokinetic muscle strength of the knee extensor and flexor muscles by the use of a computer-interfaced dynamometer. From 1997 to 2000 about half (48 %; n = 106) of all alpine WC racing events (n = 221) were won by the athletes investigated. The typical world class skier is in the mid-twenties (25.2 y [female]; 27.6 y [male]). The mean values for height were 1.66 m (female) vs. 1.81 m (male), for body mass 65.1 kg (female) vs. 87 kg (male) and for the percentage of body fat 24.5 % (female) vs. 15.8 % (male). The maximum power output was 4.3 +/- 0.4 (female ) and 4.7 +/- 0.4 W/kg (male), the corresponding values for VO(2)max were 55 +/- 3.5 (female) and 60 +/- 4.7 ml/kg/min (male). The maximal values for peak torque and work for knee extension amounted to 206 +/- 21 (female) and 334 +/- 43 Nm (male), and 2690 +/- 364 (female) and 4414 +/- 629 J (male), respectively. In both sexes there were neither significant laterality nor dysbalance. The hamstring/quadriceps ratios were between 0.57 - 0.60. Among all physical and physiological variables, only the aerobic power in males was found to be strongly correlated (r = 0.947; p = 0.001 for W (max); r = 0.964; p < 0.001 for VO(2)max) to racing performance. The study proves the practical experience that success in professional alpine skiing is not related to single physiological variables. Two main factors, however, are crucial, i. e. high levels of aerobic power and muscle strength.

Adult↗
PubMed2004

[Recent new information on epidemiology of headache].

We reviewed the epidemiology of headache disorders for the most frequent primary headache-syndromes: migraine, tension-type headache and trigemino-autonomic headache syndromes. In the last years scientific data about headache disorders have increased. New studies investigated not only the prevalence of headaches, but also economic costs of this disorder. Epidemiologic headache research also investigates the quality of life.

Autonomic Nervous System Diseases↗
PubMed2004

[Current state of uterine artery embolization for treating symptomatic leiomyomas of the uterus].

A number of new approaches in treating symptomatic leiomyomas of the Uterus have been introduced in recent years. Only little scientific data is available an percutaneous or laparoscopic myolysis using focussed ultrasound, laser, or coagulation guided by magnetic resonance imaging or an laparoscopic ligation of the uterine vessels by means of bipolar coagulation or clipping. Established therapeutic options are limited by a number of disadvantages, except for total laparoscopic hysterectomy with morcellation. The latter is a minimally invasive procedure that spares important pelvic structures and thereby reduces the risk of prolapse and is associated with rapid recovery of the patients. Another minimally invasive therapeutic approach with preservation of the uterus is transarterial catheter embolization of uterine leiomyomas in which the vessels supplying the leiomyomas, in particular the branches of the uterine artery, are partly occluded by injection of synthetic (polyvinyl) beads. Uterine artery embolization has since developed into a good alternative to other therapeutic options. Studies report cure rates ranging from 77-93 %.

Embolization, Therapeutic↗
PubMed2004

[Healing time of foot and ankle fractures in patients with diabetes mellitus: literature review and report on own cases].

BACKGROUND: It is widely believed that diabetes mellitus affects fracture healing. This assumption is based on a single case report by Cozen (1972), and has never proved by scientific data ever since. OBJECTIVES: To extract from the literature the current knowledge on the outcome of closed ankle and foot fractures in diabetics, and to review own cases from patients' charts. Outcome criteria was the healing time. METHODS: The literature was searched using MEDLINE for the years 1983-2003, under the key words "diabetes and fractures". Own cases of ankle fractures (28 diabetic, and 17 non-diabetic control cases), and of foot fractures (35 diabetic cases with Charcot-fractures) were analysed in retrospect. RESULTS: The literature search yielded 466 hits, but not one single prospective, controlled study on fracture healing time in diabetics. Three papers contained data on healing time of ankle fractures, according to which ankle fractures in diabetics take only a little longer to heal than in non-diabetics. This is consistent with our own cases: in the diabetic subjects (HbA1c 8.5 %), the fractures had healed within 3.5 months (median), versus 3 months in the non-diabetic subjects. According to 3 papers found by MEDLINE search, Charcot-fractures of the foot will heal within 3-7 months; our own cases healed within 3-5 months (median). According to the literature, treatment of Charcot foot fractures is delayed by 3 months, due to polyneuropathy, as in our cases. In non-diabetic subjects treated immediately after trauma, foot fractures will heal within 3 months (according to the literature). CONCLUSION: The present data suggest that diabetes mellitus in general does not affect the healing of foot and ankle fractures, provided effective delivery of standard treatment in time. Diabetic complications may affect the outcome. Prospective controlled trials in fracture healing in diabetics are needed to confirm the present evaluation.

Adult↗
PubMed2005

[Concepts for a demand-oriented structuring of palliative care in the German Health Care System: the example of Lower Saxony].

Palliative care can be considered a holistic care approach for patients faced with incurable and progressive diseases in their last period of life. In this context, structural, cultural and content-related deficits are increasingly taken into account in the German health care system, however, there is a lack of scientific data. Therefore, it was the objective of an expert team at Hannover Medical School to analyse the current situation of palliative care in Lower Saxony from the perspective of health system research and to give recommendations for its further development, based on empirical studies in Lower Saxony and on a systematic national and international literature review. The study revealed that the main shortcomings were an unclear structuring and an inadequate definition with respect to other areas of care, a fundamental lack of integration in regard of routine processes of care and a lack of thorough tools for needs assessments. Therefore, a concept for the integration of palliative care in the care processes of cancer patients was developed and the specific need for hospice beds in regional districts was calculated by using parameters representing provision-related and epidemiological/demographic conditions. In comparison to current structures, an assessment of over- and undersupply as well as specific recommendations how to optimize palliative care were provided for politicians, payers and providers in Lower Saxony.

Germany↗
PubMed2006

[Recommendations on sport activities for patients with idiopathic scoliosis].

The idiopathic scoliosis is a three dimensional spinal deformity mostly occurring in female adolescents. Untreated it can progress and result in back pain, impaired lung capacity and psychosocial disorders due to the cosmetic appearance of the deformed trunk. The treatment depends on the severity of the curve and ranges from physiotherapy and observation, brace treatment to surgical treatment with partial correction and fusion of the primary curve. Patients with an idiopathic scoliosis should be encouraged to actively take part in sports activities. Positive influences on the general fitness including the lung function, on the trunk muscles and on the psyche can be expected. There are no scientific data indicating that any kind of sport activities alter the natural history of idiopathic scoliosis.

Adolescent↗
PubMedDate not supplied

Antiepileptic treatment in paediatric oncology--an interdisciplinary challenge.

Epileptic seizures are a common and clinically relevant problem in paediatric oncology. Attributable to the heterogeneity of this group of patients and a number of possible comorbidities antiepileptic treatment in paediatric oncology poses a number of diagnostic and therapeutic challenges. This requires a close interdisciplinary approach to the seizing child or adolescent. A prompt and detailed diagnostic work-up is needed in every case in order to establish the diagnosis and, equally important, to detect secondary aetiological factors, e. g. epileptogenic drugs or any acute underlying pathology, such as metabolic or toxic encephalopathies, CNS-infections or cerebrovascular events. This might offer the opportunity for a specific causative treatment and thus prevent unnecessary long-term antiepileptic drug (AED) treatment. If AED treatment is initiated several aspects have to be taken into account. Most importantly, AEDs and chemotherapeutic drugs (CTDs) may interact. Depending on the comedication this may result in reduced tumour or seizure control or unexpected toxicity of AEDs or CTDs. Understanding these interactions will allow to anticipate clinically relevant adverse effects. AED may be further complicated by side-effects, some of them of particular concern for children or adolescents, such as cognitive effects, myelotoxicity, serious rashes, endocrinological disturbances, and many more. Beside critically questioning the need for AED treatment it is therefore important to prefer AED with a good safety-profile in this population. Enzyme-inducing and inhibiting AED should be avoided if possible. Preliminary studies indicate that gabapentin and levetiracetam may provide good options in terms of efficacy and safety. However, more properly designed clinical studies are warranted to raise the level of evidence for robust clinical recommendations. Until that time, clinicians will need to continue to question current policies and adapt their daily practice to evolving scientific data.

Adolescent↗
PubMed1996

Pulse oximetry and supplemental oxygen during gastrointestinal endoscopy: a critical review.

A high proportion of the mortality and morbidity associated with endoscopic procedures may be of cardiopulmonary origin. For this reason, the appropriate degree of monitoring and prophylactic measures to be used in the sedated patient undergoing endoscopy has become a topic of discussion during recent years. The development of myocardial ischaemia during gastrointestinal endoscopy has traditionally been considered to be due to the simultaneous arterial hypoxaemia; however, recent investigations have suggested that tachycardia may be a more important pathogenic factor. No study has ever shown that pulse oximetry monitoring or supplemental oxygen will reduce the morbidity or mortality during gastrointestinal endoscopy. The current guidelines for monitoring and oxygen therapy are therefore not supported by scientific data. There is a need for further studies on the pathogenic mechanisms in myocardial ischaemia during endoscopy, and the influence of hypoxaemia on the outcome after upper and lower endoscopy should be clarified.

Arrhythmias, Cardiac↗