[The concept of social marketing--potential and limitations for health promotion and prevention in Germany]

"Social marketing" is the use of marketing principles to design and implement programmes to promote socially beneficial behaviour changes. In the field of health promotion and prevention, the systematic planning process of social marketing can offer new ideas and perspectives to the traditions of social science. Major characteristics of social marketing encompass continuous market research focussing on attitudes, motives and behavioural patterns of the target group, an integrated mix of strategic key elements, and the perpetual evaluation of all procedures. So far, however, it is unclear in how far social marketing is actually more effective than other concepts of programme planning. Furthermore, it has to be discussed whether the underlying philosophy of social marketing and its implicit understanding of relationships to the public are reconcilable with health promotion principles. In Anglo-Saxon countries, the social marketing concept has achieved widespread application and is subject to controversial scientific discussions, whereas this approach is hardly considered in German health promotion research and practice. Given the increasing call for quality management and evaluation of health promotion interventions, the social marketing concept may contribute useful insights at an operational level and thus add to a discussion on effective approaches for programme planning.

Primary fibrosarcoma of the liver infiltrating the right atrium of the heart

A rare case of a primary fibrosarcoma of the liver infiltrating the right heart is described in a 72-year-old woman. The patient presented with a history of progressive dyspnea and ascites and her general condition was poor. Preoperative cardiac magnetic resonance (CMR) imaging revealed a large mass, which originated from the liver and had infiltrated the right atrium via the inferior vena cava. The patient underwent tumor resection yet died shortly afterwards. Histologically the mass was classified as a fibrosarcoma with positive immunostaining for vimentin. We report the CMR imaging characteristics in this uncommon case. Preoperative CMR proved to be useful for clinical decision making and the planning of surgery.

Varianz der Netzhautgefäßreaktion auf Flickerlicht

AIM

The study investigated the variance of the retinal vessel response to flicker light between the right and left eyes and after a short and a medium-length time interval.

METHODS

The prospective study included 28 volunteers. In the first exam both eyes were examined. One eye selected randomly was measured again after 1 h and after 1 month. The diameter response of an arterial and venous vessel segment was measured continuously by a Dynamic Vessel Analyzer (DVA, IMEDOS, Jena). Each examination consisted of 50 s baseline measurement and three periods of 20-s flicker light provocation followed by 80 s observation. The mean of three provocational cycles was calculated as dynamic vessel response.

RESULTS

A significant correlation of the flicker response parameters between the right and left eyes was found. Arterial and venous baseline diameter, flicker light dilation, AVDQ, and BP did not change significantly between the first and follow-up examinations. There was no correlation between changes of BP and changes of vessel diameter parameters in the follow-up exams.

CONCLUSION

Flicker-evoked dilation of retinal arterioles measured by the DVA is characterized under similar conditions by small variance after short and medium-length time periods. Therefore, this parameter is suitable as a functional parameter of the regulation ability of retinal arteries.

[Goals of therapy]

Relevant criteria to assess specific diseases have been heavily discussed since Rudolf Virchow when morphologic changes represented the center of interest. However, nowadays presence and severity of disease cannot exclusively depend on the mere absence or presence of morphologic criteria anymore. The progress in basic and clinical science, moral values and economic constraints imply to reflect, concretize and ultimately operationalize the goals of medical therapy. Recent advances in molecular biology and genetics have lead to further understanding of pathophysiological mechanisms of disease and opened new ways for sophisticated and individualized therapeutical approaches. It is important to reconsider the definition of health and appropriately address functional and quality of life aspects. The categorical classification of therapeutical options, i.e. curative versus palliative therapy, does not provide satisfying answers to several clinical scenarios such as early stage prostate cancer in older adults or functional limitations in patients with peripheral arterial disease. Clinical research does acknowledge increasingly that relevant outcomes extend well beyond the quantitative prolongation of life. The scientific field of health services research is supposed to increase the evidence base of these decisions. Lastly, the goals of therapy should not be defined by physicians alone. It is important to inform the patient appropriately and discuss individual prognosis, therapeutical options and goals. Ultimately, therapy should be based on a shared decision making process.

Kardio-MRT

With cardiovascular magnetic resonance imaging (CMR), the necessity of invasive coronary angiography may be increasingly avoided. CMR provides information about the anatomy of the coronaries themselves (e.g. anomalies, aneurysm), functional information on myocardial blood flow (dobutamine-stress-MR, perfusion measurement) and detailed information on cell-mediated alterations (e.g. fibrosis, necrosis). However, visualization of distal coronary vessels and the small side branches is not yet adequate, so that complete replacement of invasive coronary angiography by CMR is not possible.

[Knowledge of colorectal cancer prevention in the Bavarian population above 50 years--survey in two districts]

PURPOSE

Colorectal cancer is the second main cause of cancer death in Germany, although several measures related to primary prevention are described, and the utilisation of existing diagnostic tools (faecal occult blood test = FOBT, colonoscopy) is known to significantly decrease incidence and mortality. However, screening rates remain low in Germany, and insufficient knowledge of prevention possibilities is assumed to be responsible. The aim of this study was to investigate the knowledge related to colorectal cancer prevention in a Bavarian population, in the context of a regional public awareness campaign ("Active against Colorectal Cancer").

METHODS

618 individuals between 50 and 90 ys of age participated in a telephone survey (m: 219, f: 399, 63.2 +/- 9.17 ys); the participants were inhabitants of two Bavarian districts. The questionnaire consisted of open-ended questions concerning preventive behaviour, colorectal cancer screening, risk factors, early warning signs and knowledge of colorectal cancer information.

RESULTS

More than 80% of participants recalled healthy diet as a possible protective factor against colorectal cancer; a distinctly smaller percentage, however, could correctly define concrete dietary factors: e. g., fruit and vegetables were named by 54.5%. 66% of participants knew that unusual rectal bleeding might be a warning sign of cancer. Colonoscopy was the screening test that was most frequently recalled (61.5%); fewer participants named FOBT (32.8%) and rectal examination (11.5%). The results demonstrate that for many knowledge items, females proved to be significantly better informed than males. The most frequent sources of colorectal cancer information were newspapers, magazines, television and/or radio (named by 76.7%), as well as physicians and pharmacies (45.1%). 11.5% of participants attended the regional public awareness campaign "Action against colorectal cancer"; this subgroup had a better knowledge of some aspects related to colorectal cancer prevention.

CONCLUSION

Evidently, the interviewed Bavarian population of 50 years or older lack knowledge of risk or protection factors for colorectal cancer. Knowledge of existing screening tests was also poor. These findings can serve as starting point for information campaigns tailored for target groups.

Determinants of myocardial response in CMR perfusion imaging using Gd-BOPTA (Multihance)

PURPOSE

Different centers and vendors use different sequences and contrast agent application schemes for MR myocardial perfusion imaging. The purpose of this study was to evaluate the role of different sequences, dosages, and injection speeds of contrast media for semiquantitative MR-perfusion assessment.

METHODS

In a pilot study with 58 consecutive patients three of the most commonly used sequences for MR myocardial perfusion imaging (T1-GrE, GrE-EPI or SSFP) were compared to each other in terms of peak myocardial enhancement and image quality. For the main part of the study dynamic first pass MR perfusion imaging (Philips Intera CV, Best, Tthe Netherlands) was performed in 24 patients using the most favorable sequence from the pilot study (SSFP) after peripheral i.v. administration of Gd-BOPTA during adenosine stress. Two doses (0.05 mmol/kg bw and 0.025 mmol/kg bw) and four different injection speeds (8, 4, 3, 2 ml/s) were used. Signal intensity time curves were determined in the LV and myocardial segments supplied by normal coronary arteries and correlation between LV and myocardial upslope as well as peak enhancement were noted.

RESULTS

The SSFP-sequence showed a higher peak enhancement when using 0.05 mmol/kg bw of Gd-BOPTA and a superior image quality for both dosage regimen compared with the other sequences and was consequently applied for the main study. A significant correlation was found between the upslopes in the LV and the myocardium (r square = 0.85, p < 0.001). However, LV and myocardial upslopes were largely independent of the dosage. Myocardial upslope was significantly slower at an injection rate of 2 ml/s compared to 3 and 4 ml/s. Higher Gd-doses led to significantly higher enhancement (p < 0.001).

CONCLUSION

In healthy myocardial segments, the myocardial upslope is mainly determined from the LV upslope. Both myocardial enhancement and upslope are largely independent from the injection rate of a contrast agent bolus as long as the injection speed is not below 3 ml/s. Myocardial enhancement, however, is dose dependent. Thus, a simple correction for LV upslope allows to normalize a wide variety of input parameters. Differences of myocardial upslope or peak signal intensity after correction should be mainly dependent on blood flow.

Magnetic resonance imaging guided catheterisation for assessment of pulmonary vascular resistance: in vivo validation and clinical application in patients with pulmonary hypertension

OBJECTIVES

To validate in vivo a magnetic resonance imaging (MRI) method for measurement of pulmonary vascular resistance (PVR) and subsequently to apply this technique to patients with pulmonary hypertension (PHT).

METHODS AND RESULTS

PVR was assessed from velocity encoded cine MRI derived pulmonary artery (PA) flow volumes and simultaneously determined invasive PA pressures. For pressure measurements flow directed catheters were guided under magnetic resonance fluoroscopy at 1.5 T into the PA. In preliminary validation studies (eight swine) PVR was determined with the thermodilution technique and compared with PVR obtained by MRI (0.9 (0.5) v 1.1 (0.3) Wood units.m2, p = 0.7). Bland-Altman test showed agreement between both methods. Inter-examination variability was high for thermodilution (6.2 (2.2)%) but low for MRI measurements (2.1 (0.3)%). After validation, the MRI method was applied in 10 patients with PHT and five controls. In patients with PHT PVR was measured at baseline and during inhalation of nitric oxide. Compared with the control group, PVR was significantly increased in the PHT group (1.2 (0.8) v 13.1 (5.6) Wood units.m2, p < 0.001) but decreased significantly to 10.3 (4.6) Wood units.m2 during inhalation of nitric oxide (p < 0.05). Inter-examination variability of MRI derived PVR measurements was 2.6 (0.6)%. In all experiments (in vivo and clinical) flow directed catheters were guided successfully into the PA under MRI control.

CONCLUSIONS

Guidance of flow directed catheters into the PA is feasible under MRI control. PVR can be determined with high measurement precision with the proposed MRI technique, which is a promising tool to assess PVR in the clinical setting.

Vergleich der Durchmesserreaktion retinaler Arterien und Venen auf Flickerlicht

PURPOSE

The aim of this study was to compare the diameter response of retinal arteries and veins after provocation with flickering light regarding the amplitude and temporal course.

METHODS

The study included 26 healthy volunteers. The vessel diameter was automatically and continuously measured by the retinal vessel analyzer. The examination consisted of a baseline measurement (100 s) followed by five periods of 20-s flicker light provocation and 80-s follow-up observation.

RESULTS

A diameter dilation was observed immediately after the end of the flicker period in arteries (6.9+/-2.8%) and veins (6.5+/-2.8%, difference n.s.). The quotient of arterial and venous dilation (AVDQ) was 1.25+/-0.69 (range: 0.2-2.8). A significant correlation of age and arterial or venous dilation or the AVDQ was not observed. The arterial diameter reduced faster than the venous and reached a minimum of -2.7+/-1.4% at 25.9+/-10.8 s after the end of the flicker phase. The veins were dilated by 0.5+/-1.3% at the time of the maximal individual arterial constriction (p<0.0001).

CONCLUSIONS

Flicker-evoked response of retinal arteries and veins did not differ in the dilative amplitude but in the temporal course of the abatement of the dilation.

Cyclosporine C2 levels in de novo renal allograft recipients: a German multicenter prospective observational study

This ongoing multicenter prospective observational study was undertaken in de novo renal allograft recipients managed with cyclosporine (CsA) trough (C0) and 2-hour postdose (C2) level monitoring at defined times so as to assess the risk for an acute rejection episode or allograft dysfunction. The renal transplant recipients (n = 159) were enrolled at 11 German centers. The 6-month posttransplant data from 138 patients were evaluable for this interim analysis. Mean C2 levels (ng/mL), which were measured by liquid chromatography-tandem mass spectrometry at a central laboratory, were: days 3 to 5: 873.1 +/- 391.9; days 7 to 10: 939.1 +/- 422.8; days 14 to 28: 1116.3 +/- 497.6; 3 months: 905.0 +/- 316.8; and after 6 months: 787.0 +/- 276.5. To identify patients at higher risk for acute rejection or allograft dysfunction, we calculated the relative CsA absorption capacity (C2 [ng/mL]/morning dose [mg/kg]; CsA-Abs), yielding mean values on days 3 to 5: 284.4 +/- 115.1; days 7 to 10: 306.7 +/- 134.8; days 14 to 28: 382.5 +/- 164.7; month 3: 501.5 +/- 168.8; month 6: 512.7 +/- 176.5. Three groups were distinguished by CsA-Abs at days 7 to 10: low absorbers (CsA-Abs < 200), normal absorbers (CsA-Abs 200 to 350), and high absorbers (CsA-Abs > 350). A between-group comparison of absorption level at 6 months posttransplant revealed the incidences of biopsy-proven acute rejection and Cockcroft-Gault formula-based mean glomerular filtration rates of 23.8% and 54.7 +/- 19.0 mL/min, 22.6% and 59.5 +/- 20.7 mL/min, and 17.6% and 67.7 +/- 23.5, respectively. In conclusion, mean C2 levels >1000 ng/mL are attained within 2 to 4 weeks, with CsA-Abs increasing continuously over the first 6 posttransplant months. High CsA absorbers show a propensity toward good allograft function and lower acute rejection rates at 6 months after renal transplantation.

[Spectral separation in ocular fundus autofluorescence images in patients suffering from age-related macular degeneration]

INTRODUCTION

Alterations in the intrinsic ocular fundus fluorescence are under discussion particularly in connection with age-related macular degeneration. However, further knowledge of the chemical substrate of fluorescence is necessary.

METHOD

Ocular fundus autofluorescence was observed using a fundus camera. The fluorescence emission was recorded using a 3-chip CCD camera. For comparison, the fluorescence spectra of lipofuscin, A2-E, FAD, NADH(2) and AGE's were recorded by the Jena ophthalmo-spectrometer.

RESULTS

In contrast to the homogeneous intrinsic fluorescence of a normal fundus, the fluorescence images of patients suffering from AMD showed remarkable local differences. The detected fluorescence spectra showed remarkable overlaps.

DISCUSSION

We introduced a new technique enabling the detection of spectral differences in images of ocular fundus autofluorescence. Besides the fluorescence of lipofuscin, we found a green one in patients suffering from nonexudative AMD.

Bedeutet Evidenz-basierte Chirurgie eine Abkehr von der ärztlichen Therapiefreiheit?

Evidence-based clinical guidelines in surgery are frequently confronted with scepticism by the medical staff, especially because a confinement of free decision making in therapy is expected. Considering that medicine is not merely natural science, but can as well be comprehended as social science or art, evidence-based medicine (EbM) may lead to an oversimplified and rigid standardization in medical care ("cook book medicine"). In addition, scientific progress might be prevented by inflexible guidelines. However, it is important for surgeons to engage in the development of evidence-based guidelines in order to put forward their interests, because it is the lack of medical guidelines that might threaten free decision making in surgery - by not confronting economical pressure with decisive minimal standards in medical care. Therapeutical freedom is a substantial principle in medicine, but it should be considered that according to occidental tradition, "freedom" is necessarily involving reason and conscientiousness.