[Palliative medicine content in German-language medical textbooks]

BACKGROUND

There is a need for improved end-of-life care, especially in the light of demographic changes with an increased incidence of cancer. Although medical textbooks are central to the training of medical students and also serve as a reference for more experienced clinicians, only few data exist on the extent to which medical textbooks address end-of-life care. We analysed the quantity and quality of information on end-of-life care given in German textbooks on different medical disciplines.

MATERIAL AND METHODS

26 top-selling German medical textbooks were analysed for the presentation of end-of-life care in chapters that address the 13 most common causes of death worldwide

RESULTS

In the 159 chapters analysed for information on traditional topics, like risk factors or early diagnosis (group A), such information was provided in 52% compared with only 9% on end-of-life topics, such as symptom management or manner of death (group B) (p=0.0001). There was no statistically significant difference between the different medical specialities (p=0.22). Line-by-line analysis showed that the phrase death or related terms was mentioned in only 57 of 159 chapters dealing with the most common causes of death worldwide.

CONCLUSION

The top-selling German textbooks that were analysed generally offer little helpful information on end-of-life care of patients.

Substantia nigra echomorphology in the healthy very old: Correlation with motor slowing

Transcranial sonography reveals an increase in echogenicity in the substantia nigra of patients with idiopathic Parkinson's disease. Marked hyperechogenicity has also been described in 9% of the healthy population and is associated with subtle clinical or functional neuroimaging findings suggestive of changes in nigrostriatal function. It has therefore been hypothesised that a hyperechogenic substantia nigra represents an early stage of nigral degeneration or a predisposition for Parkinson's disease. In the present study, we correlated sonographic findings with motor and cognitive deficits in a group of healthy, very elderly subjects. Marked and moderately increased substantia nigra echogenicity was present in 25% and 21% of our healthy, very elderly subjects, respectively, and correlated strongly with the presence of extrapyramidal symptoms in the absence of cognitive deficits. The high incidence of substantia nigra hyperechogenicity measured in our very elderly subjects compared with previous TCS studies suggests that the prevalence of this feature increases with age and is consistent with the higher prevalence of Parkinson's disease in advanced age, as well as the increased frequency of extrapyramidal symptoms. Our results indicate that this simple technique can be used to identify and quantify brain changes associated with subtle motor dysfunction in the very elderly.

CD117 (c-kit) expression in human hepatocellular carcinoma

AIMS

Although various methods of treatment have been tried, treatment options for advanced hepatocellular carcinoma (HCC) remain limited. Expression of the platelet-derived growth factor has been shown in HCC, which may derive from hepatic stem cells that express the c-kit proto-oncogene. Because of the promising results of imatinib and the key role played by c-kit in gastrointestinal stromal tumours and other solid tumours, the aim of this study was to determine the prevalence of c-kit (CD117) overexpression in patients with HCC.

MATERIALS AND METHODS

A retrospective study of 258 archival specimens of subjects with histologically confirmed HCC was carried out. Expression of the c-kit proto-oncogene was evaluated by immunohistochemistry using rabbit anti-CD117 antibody A4502.

RESULTS

The overall percentage of positive immunohistochemical staining of HCCs was 2.3% (6/258).

CONCLUSIONS

Our results suggest that CD117 is not significantly overexpressed in HCC and there seems to be no role for the use of imatinib.

Transboundary flood management in the Rhine basin: challenges for improved cooperation

An appropriate institutional set up is essential for efficient transboundary flood management in the Rhine basin, particularly in view of future uncertainties like climate change. Flood management factors are identified based on a historical comparison in the Netherlands and Germany. They include differences in the perception of the problem and how to solve it; in the understanding of key items and how to address them; in administrative responsibilities and the political will to act. Suggestions are made to improve cooperation, in particular to generate a common problem perception and problem analysis, to develop a common vision for future flood strategies and to create a network of discussion platforms to promote social learning and to prepare, decide and implement flood management issues.

Direct reaction of oximes with crotylsarin, cyclosarin, or VX in vitro

The direct reaction of seven pyridinium oximes with the organophosphorus compounds (OPCs) crotylsarin, cyclosarin, and VX was studied by spectrophotometry. This method allows to quantify different parameters: (a) the half-life times (t (1/2)) of the oxime-OPC reactions on the basis of the changes in the absorption at the zwitterion (betaine) peak maximum, (b) the first- and second-order rate constants (k (1), k (2)), and (c) the maximum reaction velocities (v (max)). The results of the study show that the reaction velocity of the nerve agents with any of the oximes investigated decreased in the order crotylsarin > cyclosarin > VX. The comparison of the reaction rates of the three therapeutically used oximes (2-PAM, obidoxime, HI 6) with the respective OPC gave the highest rate for crotylsarin and cyclosarin with obidoxime and to a similar degree with HI 6, while in the case of VX the most reactive oxime was HI 6. The reaction velocity of the nerve agents with the monopyridinium oxime 2-PAM was lower as compared to the bispyridinium oximes (obidoxime, HI 6). The results obtained with the two sarin analogues indicate that the direct reaction with 2-PAM, obidoxime, or HI 6 could be used for non-corrosive decontamination purposes, especially, if sensitive biological surfaces like skin, mucous membranes, or wounds are considered. However, in view of the concentrations of nerve agents and oximes, which could be expected during OPC poisoning in man, the maximum reaction velocities would not be high enough to contribute markedly to the detoxication of nerve agents in vivo.

Rehabilitationsverlauf und Nachhaltigkeit—

A rehabilitation care management oriented towards the severity of the disease, the individual competence and the patient's needs essentially improves the effectivity and the sustainability of inpatient rehabilitation. The Institute of Gerontology of the University of Heidelberg is developing an assessment for elderly stroke patients to optimize placement decision by an early rehabilitation prognosis. Data concerning functional, cognitive and psychological status were collected in 267 patients participating in a postacute rehabilitation program on admission, after two weeks and on discharge and six weeks later. In this article are presented the study design and patients' characteristics during the rehabilitation process. The first assessment at admission gives important information about the sustainability of the ADL-competence after discharge. Severe stroke, premorbid ADL-competence, cognitive impairment, communication problems, depression and higher age were found to be predictors for the outcome of the rehabilitation process.

Combination of celecoxib with percutaneous radiotherapy in patients with localised prostate cancer - a phase I study

BACKGROUND

Current approaches for the improvement of bNED for prostate cancer patients treated with radiotherapy mainly focus on dose escalation. However molecularly targeted approaches may also turn out to be of value. In this regard cyclooxygenase (COX)-2 inhibitors have been shown to exert some anti-tumour activities in human prostate cancer in vivo and in vitro. Although in vitro data indicated that the combination of COX-2 inhibition and radiation was not associated with an increased toxicity, we performed a phase I trial using high dose celecoxib together with percutaneous radiation therapy.

METHODS

In order to rule out any increases of more than 20% incidence for a given side effect level 22 patients were included in the trial. Celecoxib was given 400 mg twice daily with onset of the radiation treatment. Risk adapted radiation doses were between 70 and 74 Gy standard fractionation. RTOG based gastrointestinal (GI) and genitourinary (GU) acute toxicity scoring was performed weekly during radiation therapy, at six weeks after therapy and three month after completing radiation treatment.

RESULTS

Generally no major increase in the level and incidence of side effects potentially caused by the combined treatment was observed. In two cases a generalised skin rash occurred which immediately resolved upon discontinuation of the drug. No grade 3 and 4 toxicity was seen. Maximal GI toxicity grade 1 and 2 was observed in 85% and 10%, respectively. In terms of GU toxicity 80% of the patients experienced a grade 1 toxicity and 10 % had grade 2 symptoms.

CONCLUSION

The combination of irradiation to the prostate with concurrent high dose celecoxib was not associated with an increased level of side effects.

Ceruloplasmin gene variations and substantia nigra hyperechogenicity in Parkinson disease

BACKGROUND

Transcranial ultrasound may be used to detect increased iron levels of the substantia nigra (SN) in patients with Parkinson disease (PD) and in control subjects. It is not known whether iron accumulation in PD is a primary or secondary phenomenon. However, sequence variations in genes involved in iron metabolism have been linked to basal ganglia disorders. One of these is ceruloplasmin (Cp), which is vitally involved in iron transport across the cell membrane.

METHODS

One hundred seventy-six patients with PD according to the UK Brain Bank criteria and 180 ethnically matched control subjects, who were previously examined for SN iron signal changes by transcranial ultrasound, were examined for mutations in the Cp gene using denaturing high-performance liquid chromatography and subsequent sequencing for verification of unequivocal signals. Immunohistochemistry of PD midbrains was performed to examine the presence of Cp in Lewy bodies.

RESULTS

Five novel missense variations were detected. One of these (I63T) was found in a single PD patient. A known variation (D554E) was significantly associated with PD and the ultrasound marker for increased SN iron levels. Moreover, a third sequence variation (R793H) was found to segregate with the ultrasound marker for increased iron levels in patients and control subjects. Immunohistochemistry demonstrated that Cp co-localizes with Lewy bodies in PD.

CONCLUSIONS

Detection of sequence variations in a single Parkinson disease (PD) patient or associated with the ultrasound marker for increased substantia nigra iron levels and the presence of ceruloplasmin (Cp) immunoreactivity in Lewy bodies underline a suspected role for Cp in the pathogenesis of PD. Further functional analyses are warranted to investigate whether these variations are causally linked to the complex pathogenesis of PD in a subset of cases.