Abstract P1-13-01: Final results of the ASG1-3 study, a randomized phase III study comparing a standard dose chemotherapy with epirubicin/cyclophosphamide and paclitaxel with a dose dense regimen with epirubicin and paclitaxel

Background

Dose dense chemotherapy (DDT) has shown improvements of disease-free survival (DFS) and overall survival for primary breast cancer patients with a high risk of relapse. There are much less data about the effect of DDT in patients with intermediate risk of recurrence (1-3 positive axillary lymph nodes). Aim of this prospectively randomized trial was to investigate the superiority of a DDT schedule over a standard chemotherapy (ST) in primary breast cancer patients with 1-3 positive axillary lymph nodes.

Methods

The ASG1-3 study is a prospectively randomized, open label phase III study of the Adjuvant Study Group of the NOGGO association. Patients were eligible for the trial, if they had a primary invasive breast cancer (pT1-3) with 1-3 positive axillary lymph nodes and no evidence of distant metastases. Patients were randomized to an adjuvant therapy with either 4 cycles epirubicin (90mg/m2 body surface area, BSA) and cyclophosphamide (600mg/m2 BSA) q3w, followed by 4 cycles of paclitaxel (175mg/m2 BSA) referred to as ST or to a therapy with 4 cycles of epicubicin (120 mg/m2 BSA) q2w and primary G-CSF support followed by 4 cycles of paclitaxel (175mg/m2 BSA) q2w and primary G-CSF support referred to as DDT. Trastuzumab was not given in this study. The study was designed to show an increase of 70% DFS (ST) to 80% DFS (DDT) 5 years after randomization. Comparisons were conducted using Kaplan Meier estimates, log rank tests and Cox regression analyses. In an exploratory way, subgroup analyses were performed for HER2, hormone receptor status and grading using Cox regression models with interaction terms.

Results

A total of 936 patients were eligible for survival analysis, of which 465 were randomized to ST and 471 to DDT from 2001 to 2004. Patient characteristics were mainly well balanced, with patients being 52.5/52.1 years old, 71.9/78.1% being hormone receptor positive, 24.4/24.6% being HER2 positive and 38.6/38.8% having a tumor grade of 3 in the ST arm and DDT arm respectively. 53 events occurred after ST and 46 after DDT. Adjusted hazard ratio (HR) was 0.87 (95%CI: 0.57-1.35; p=0.54). 5 year DFS rates were 85% (ST) vs. 87% (DDT). Hematological toxicities were the most common grade 3 or 4 adverse events. Grade 3/4 neutropenia occurred in 57.2 vs. 28.0%, grade 3/4 anemia in 15.3% vs. 17.1% and grade 3 /4 pain symptoms were seen in 13.2 vs. 12.4% of the patients in the ST arm vs. DDT arm respectively. Other grade 3/4 toxicities were less frequent than 10%. Subgroup analysis showed a significant interaction (p<0.001) between HER2 status and randomization arm with regard to DFS. In HER2 negative patients the HR was 1.53 (95%CI: 0.91-2.59), whereas in HER2 positive patients the HR was 0.22 (95%CI: 0.09-0.55). Patients with HER2 positive disease and DDT had a similar prognosis like HER2 negative patients.

Conclusion

In the overall population a statistically significant improvement of DFS could not be shown for the DDT arm. In patients with HER2 positive breast cancer DDT chemotherapy improved the disease-free survival to a prognosis which was similar to patients with HER2 negative disease.

Citation Format: Fasching PA, Eggemann H, Krocker J, Häberle L, Volz B, Kleine-Tebbe A, Blohmer J-U, Kittel K, Hufnagel M, Janni W, Emons G, Simon E, Köhler U, Thomssen C, Kohls A, Beckmann MW, Hielscher C, Krabisch P, Zeiser T, Brodkorb T, Baier F, Nabieva N, Kellner S, Untch M, Stadie S, Budner M, Breitbach G-P, Keller M, Stickeler E, Kühn T, Tolkmitt M, Belau AK, Schmidt M, Ulm K, Kümmel S. Final results of the ASG1-3 study, a randomized phase III study comparing a standard dose chemotherapy with epirubicin/cyclophosphamide and paclitaxel with a dose dense regimen with epirubicin and paclitaxel [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-13-01.

Neural Network Analysis of Follow-Up Data in Primary Breast Cancer

This paper reports on the performance of a recently developed neural network environment incorporating likelihood-based optimization and complexity reduction techniques in the analysis of breast cancer follow-up data with the goal of building up a clinical decision support system. The inputs to the neural network include classical factors such as grading, age, tumor size, estrogen and progesterone receptor measurements, as well as tumor biological markers such as PAI-1 and uPA. The network learns the structural relationship between these factors and the follow-up data. Examples of neural models for relapse-free survival are presented, which are based on data from 784 breast cancer patients who received their primary therapy at the Department of Obstetrics and Gynecology, Technische Universität München, Germany. The performance of the neural analysis as quantified by various indicators (likelihood, Kaplan-Meier curves, log-rank tests) was very high. For example, dividing the patients into two equally sized groups based on the neural score (i.e., cutoff = median score) leads to an estimated difference in relapse-free survival of 40% or better (80% vs. 40%) after 10 years in Kaplan-Meier analysis. Evidence for factor interactions as well as for time-varying impacts is presented. The neural network weights included in the models are significant at the 5% level. The use of neural network analysis and scoring in combination with strong tumor biological factors such as uPA and PAI-1 appears to result in a very effective risk group discrimination. Considerable additional comparison of data from different patient series will be required to establish the generalization capability more firmly. Nonetheless, the improvement of risk group discrimination represents an important step toward the use of neural networks for decision support in a clinical framework and in making the most of biological markers.

Evaluation of Non-invasive Examinations of Coronary Artery Disease Using Information Theory

A method is presented which allows a stepwise selection of relevant variables for a diagnosis and also a sequential allocation bearing in mind the time-sequence and the expense in recording the variables. The method is based on an information-theoretical approach and is suitable for the application of qualitative variables. The method is presented using data concerning patients with suspected coronary artery disease, taking into consideration the fact that the variables are observed at different times.

Impingement-free range of movement, acetabular component cover and early clinical results comparing ‘femur-first’ navigation and ‘conventional’ minimally invasive total hip arthroplasty

We report the kinematic and early clinical results of a patient- and observer-blinded randomised controlled trial in which CT scans were used to compare potential impingement-free range of movement (ROM) and acetabular component cover between patients treated with either the navigated ‘femur-first’ total hip arthroplasty (THA) method (n = 66; male/female 29/37, mean age 62.5 years; 50 to 74) or conventional THA (n = 69; male/female 35/34, mean age 62.9 years; 50 to 75). The Hip Osteoarthritis Outcome Score, the Harris hip score, the Euro-Qol-5D and the Mancuso THA patient expectations score were assessed at six weeks, six months and one year after surgery. A total of 48 of the patients (84%) in the navigated ‘femur-first’ group and 43 (65%) in the conventional group reached all the desirable potential ROM boundaries without prosthetic impingement for activities of daily living (ADL) in flexion, extension, abduction, adduction and rotation (p = 0.016). Acetabular component cover and surface contact with the host bone were > 87% in both groups. There was a significant difference between the navigated and the conventional groups’ Harris hip scores six weeks after surgery (p = 0.010). There were no significant differences with respect to any clinical outcome at six months and one year of follow-up. The navigated ‘femur-first’ technique improves the potential ROM for ADL without prosthetic impingement, although there was no observed clinical difference between the two treatment groups.

Cite this article: Bone Joint J 2015; 97-B:890–8.

WITHDRAWN: Rationale and Design of a Randomised Controlled Trial Comparing Stent-Protected Angioplasty with Bypass Surgery for Intermittent Claudication: The ABC Study

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Muscle relaxant use for tracheal intubation in pediatric anaesthesia: a survey of clinical practice in Germany

OBJECTIVES

Aim of this Germany-wide study was to evaluate the use and application customs of neuromuscular blocking drugs (NMBDs) for tracheal intubation in children of age 5 years or younger.

MATERIAL AND METHODS

In the year 2005, a total of 3260 questionnaires were sent out to all heads of anesthesia departments at all types of hospitals as well as ambulatory anesthesia centers in Germany. The fields covered by the questionnaire were regarding institutional size, amount of general anesthesia and specifically pediatric cases, number of intubations and NMBDs used, frequency of use of the individual relaxants and techniques utilized when administering muscle relaxants.

RESULTS

Of the sent-out questionnaires 66.9% could be analyzed: 82% of hospitals use 1-3 muscle relaxants in children; 91% of the ambulatory anesthesia centers use a repertoire of 1-2 neuromuscular blockers for pediatric cases. However, general anesthesia with tracheal intubation in children is often induced without using any NMBD at all. Mivacurium is the predominantly used NMBD for pediatric intubation in Germany. In contrast, the use of succinylcholine is far less in ambulatory anesthesia centers than in hospitals. Despite controversial discussion, precurarization, priming, and timing are still utilized in German anesthesia practice.

CONCLUSION

In Germany, mivacurium, with its favorable pharmacologic profile for short cases, is the predominantly used NMBD for pediatric tracheal intubation. Despite the known adverse effects of intubation without muscle relaxation, this technique is also wide-spread, especially among German anesthetists in ambulatory anesthesia centers. Surveys like these are important to determine a status quo of use and application customs of NMBDs in pediatric anesthesia and provide a basis for numerous other studies.

[MCI-plus: mild cognitive impairment with rapid progression. Part II: Biomarkers and research methods]

Long-term studies will be pivotal in order to examine the efficacy of preventive and early therapeutic interventions during the preclinical phase of dementia. Biomarkers will be of importance due to the large sample sizes and the necessary logistic efforts, high drop-out rates and slow clinical progression. The validity of functional and even structural imaging methods is currently investigated with early and promising results; it is presently unclear whether conventional csf-markers of Alzheimer's disease (beta-amyloid and tau-proteins) are sufficiently sensitive to monitor the effects of early interventions. It also remains doubtful whether modifications of these methods will ever be useful and available for practical purposes.

[MCI-plus: mild cognitive impairment with rapid progression. Part I: prevention and therapy]

Mild Cognitive Impairment (MCI) is a prevalent problem in the elderly and many patients show predictors of rapid cognitive decline ("MCI-plus"). MCI-plus represents a syndrome with growing importance in an ageing society, which will increasingly affect primary medicine and most other clinical specialties. We will have to face the dilemma of fast progress in the field of neurodiagnostics with innovative therapeutic strategies lagging behind. Psychological and medical co-morbidity in MCI-plus will therefore offer important opportunities to delay and to avoid the manifestation of dementia. We will review and discuss current training and treatment options including symptomatic and causal interventions.

Tumor-specific correlation of tumor-type M2 pyruvate kinase (Tu M2-PK) in patients with cervical carcinoma

5044

Background: Pyruvate kinase is a key enzyme in glycosis. Proliferating cells express the tetrameric isoenzyme pyruvate kinase type M2 (M2-PK), which decomposes to the dimeric form during tumor development (Tu M2-PK). This suggests that Tu M2-PK can be used as a tumor marker. The goal of the present study was to investigate the diagnostic value of Tu M2-PK in patients with cervix carcinoma and in patients with preinvasive lesions (CIN I-III). Methods: Plasma samples were investigated from a total of 116 patients using the quantitative sandwich enzyme immunoassay for Tu M2-PK (ScheBo, Tech GmbH). The patients were divided up into 3 groups depending on the severity of their condition: Group 1 (n = 43): CIN I-III; Group2 (n = 49): cervix carcinoma FIGO stage I-IV; Group3 (n = 24): relapse of cervical cancer. Results: The differentiation into three groups depending on the severity of the condition gave significant results, with the group of patients with relapsed cervix carcinoma having the highest concentration of Tu M2-PK (p < 0.001) (mean rank: Group 1 - 33.67, Group 2 - 62.48, Group 3 - 94.85 U/ml). In addition, there was a significant differentiation with respect to the FIGO stage, with increasing concentration for increasing stages (p < 0.001). In contrast with this there was no significant differentiation in patients with preinvasive lesions (p < 0.99). In the evaluation of the correlation with prognosis factors of cervix carcinoma (lymph-node status: N(+), N(−); lymphangioinvasion: L1;L0; angioinvasion: V1, V0 and grading G1–3) there were significantly higher values with positive lymph nodes (N+) (p < 0.0001). No significant differences were determined in the analysis of different tumor sub-types (squamous cell carcinoma, adenocarcinoma, adeno-squamous cell carcinoma) (p = 0.076). Conclusions: These are first results which indicate that Tu M2-PK can be used as a marker to differentiate between malignant and premalignant lesions for patients with cervical cancer. In addition, the concentration correlates with the stage of the disease.

No significant financial relationships to disclose.

Analysis of the VEGF family and their receptors in serum/plasma of patients with pre-invasive and invasive cervical cancer

5016

Background: The vascular endothelial growth factor (VEGF) family and their receptors are essential regulators of angiogenesis and lymphangiogenesis. This study examined the significance of circulating VEGF, VEGF-C, VEGF-D and their receptors VEGFR-1 and VEGFR-2 in patients with preinvasive and invasive cancer in relation to conventional prognostic parameters. Methods: Blood samples were obtained from 125 women before initial treatment (CIN I-III n = 50; FIGO stage I-IV n = 51; relapse n = 24). Plasma (p) and serum(s) levels of pVEGF, sVEGF-D, sVEGFR-1, sVEGFR-2 (R&D Systems, USA) and sVEGF-C (IBL, Japan) were determined by using a quantitative sandwich enzyme-linked immunosorbent assay (ELISA). Results: The highest level of pVEGF (p = 0.007) and sVEGFR-2 (p = 0.014) were detected in patients with recurrent disease, whereas the highest level of sVEGF-D (p = 0.046) were measured in patients with preinvasive lesions (CIN I-III). Furthermore, significantly elevated levels of sVEGF-C (p = 0.021) were detected in early stages (FIGO I-II) in comparison with advanced stages (FIGO III-IV) of cervical cancer. No significant difference in concentration was observed between the various grades of cervical intraepithelial neoplasia (CIN I-III). Correlations between conventional prognostic markers such as lymph node status (N0/N1), lymphangioinvasion (L0/L1), angioinvasion (V0/V1) and grading (G1/G2/G3) were investigated. Increased plasma levels of VEGF (p = 0.036) correlate with the dissemination of tumor cells to regional lymph nodes (N1),whereas serum VEGF-D levels were significantly decreased in women with lymph-node involvement (N1) (p = 0.045) and vascular invasion (L1) (p = 0.019). None of these members of the VEGF family were found to correlate significantly with histological subtype (squamous cell carcinoma, adenocarcinoma, adeno-squamous cell carcinoma) or grading of the tumor cells (G1/G2/G3). Conclusions: These results show that circulating concentrations of VEGF are associated with the stage of disease. In an early stage of cervical cancer a switch to a lymphangiogenic phenotype (VEGF-D, VEGF-C) might be possible.

No significant financial relationships to disclose.

FGFR4 Arg388 allele is associated with resistance to adjuvant therapy in primary breast cancer

625

Background: Bange et al. recently found that a single-nucleotide polymorphism (SNP) at codon 388 of fibroblast growth factor receptor 4 (FGFR4) gene, causing a transmembrane domain missense mutation (Gly388Arg), is associated with outcome in node-positive breast cancer. Methods: This study addresses clinical relevance of this SNP, FGFR4 genotype, phenotype, and HER2 regarding patient outcome and influence of adjuvant systemic therapy in a substantial primary breast cancer collective (n=372; 1987–2002), median follow-up 94.5 months. Treatment was administered according to consensus recommendations at the time: 73 patients (all N0) received no adjuvant systemic therapy; 114 received adjuvant chemotherapy (87% CMF-based), 164 tamoxifen, 10 combined chemo-endocrine therapy, 11 unknown. 128 (36%) patients experienced disease recurrence, 104 (81%) distant relapses; 140 (38%) died. PCR-RFLP-analysis of germ-line polymorphism was performed in uninvolved lymph nodes; FGFR4 and HER2 expression were assessed immunohistochemically in tumor tissue arrays. Primary endpoint was DFS, since it best reflects impact of adjuvant systemic therapy. Results: In 51% of patients, homo- or heterozygous Arg388 allele was present. No correlation existed between FGFR4 genotype and expression or HER2 status. In N0 patients, FGFR4 genotype was not correlated with disease outcome. In N+ patients, however, FGFR4 Arg388 was significantly associated with poor DFS (p=0.02) and OS (p=0.04). Notably, this association seems to be attributable to relatively poor therapy response in Arg388 carriers, reflected in their significantly shorter DFS (p=0.02) and OS (p=0.045) among patients receiving adjuvant systemic therapy. It is also seen as a significant interaction term in a multivariate proportional hazards model with Arg388 carriers having only about half as much benefit from adjuvant systemic therapy as wild-type carriers. Conclusions: Our results show that the previously found association of FGFR4 Arg388 genotype with breast cancer progression is strongest in patients with adjuvant systemic therapy, particularly chemotherapy, and thus may reflect therapy resistance.

No significant financial relationships to disclose.

Muskelrelaxanzien in Deutschland 2005

Aim of this study was to evaluate application customs of muscles relaxants in hospitals compared to their use in private practice. Of the 3,260 questionnaires sent-out, 66.9% could be analyzed. Of these 54% were from anesthetists in private practice, 41% from heads of hospital anesthesia departments and 5% from heads of level one hospital anesthesia departments. The first difference between private practices and hospitals was the number of available muscle relaxants: 87% of private practices use 1-3 relaxants, whereas 79% of hospitals use 3-5. Another apparent difference was the relationship between general anesthesia and the number of intubations: 60% of private practices have over 80% of general anesthesia cases, but only 50% of these patients are intubated. On the contrary, two thirds of the hospitals have 50-80% general anesthesia cases and 60-70% of patients are intubated. The main wish for an ideal muscle relaxant was independent of private practice or hospital, short onset time, followed by fast recovery. In accordance 74% of anesthetists in hospitals and 72% of anesthetists in private practice voiced the wish for a non-depolarizing succinylcholine substitute. The results of this nationwide survey suggest that time pressure in combination with an increased specialization of anesthetists in private practice are the main factors for availability and use of muscle relaxants in routine anesthesia.

Blood interleukin 12 as preoperative predictor of fatal postoperative sepsis after neoadjuvant radiochemotherapy

Introduction

The value of preoperative whole-blood interleukin (IL) 12 levels in predicting death from postoperative sepsis was evaluated, in patients stratified by underlying malignancy, neoadjuvant tumour treatment and surgical procedure.

Methods

Blood samples were collected from 1444 patients before major surgery. Whole blood was incubated with Escherichia coli lipopolysaccharide (LPS) and IL-12 production in supernatants was assessed by enzyme-linked immunosorbent assay. The prognostic impact of ability to synthesize IL-12 before surgery was investigated in patient subgroups with respect to sepsis-related mortality using multivariate binary logistic regression analysis.

Results

IL-12 synthesizing capability in patients who survived sepsis was significantly higher than that in patients who developed fatal sepsis (P = 0·006). In multivariate analysis only IL-12 was associated with a lethal outcome from postoperative sepsis (P = 0·006). The prognostic impact of IL-12 was evident in patients with underlying malignancy (P = 0·011) and in those who had undergone neoadjuvant tumour treatment (P = 0·008). When patients were analysed according to the type of neoadjuvant therapy, preoperative ability to synthesize IL-12 had a significant prognostic impact in patients who had neoadjuvant radiochemotherapy (P = 0·026), but not in those who had neoadjuvant chemotherapy.

Conclusion

IL-12 production after stimulation of whole blood with LPS appears to be useful for the preoperative assessment of risk of sepsis-related death after operation in patients who have undergone neoadjuvant radiochemotherapy.

Influence of pollen feeding and physiological condition on pesticide sensitivity of the honey bee Apis mellifera carnica

In two consecutive years heavy bee mortality at end April/early May followed the use of pesticides classed as harmless for bees along road verges. It was thought that old weak winter bees had succumbed to a preparation otherwise innocuous. Extensive tests to reveal any links between the bees' physiological condition and pesticide sensitivity involved 6 hormone herbicides, 11 fungicides and 2 insecticides, all approved harmless for bees and functioning on them wholly or mainly as stomach poisons. As a rule bee sensitivity was measured as LD 50 per os, in smaller tests as percentage mortality. Amount and quality of pollen ingested in the first days of life affected the pesticide sensitivity of young and older bees. Bees fed adequate high quality pollen are less sensitive than counterparts fed inadequate or inferior pollen or pollen substitute; such differences persisted if the LD 50 was calculated for the same body weight. Pesticides containing manganese are an exception. To these, bees fed inadequate pollen are no more or even less sensitive than comparable well-fed bees. Pesticide sensitivity decreases generally from early to late summer. Quality of pollen available for larvae has no effect on poison sensitivity of imagines. Food supply conditions however exert a clear influence: tested with the same pesticides, hive bees from colonies having had a rich early food supply, and young bees bred then, are less sensitive than their counterparts having had moderate or no early food supply. Poison sensitivity of summer bees increases with age; most sensitive are old winter bees which had practiced broodcare in early spring.Inadequate pollen intake can be regarded as causing protein deficiency. Investigation of this in mammals and man indicate that the higher poison sensitivity in bees results from inhibition of the enzymatic decomposition of pesticides. For practical bee protection it is important that all organic fungicides tested are effectively harmless. Hormone hebicides can be ranked as practically harmless even for bees inadequately protein-fed, as long as the approved concentrations are observed. Our tests raised doubts however about the registration as harmless for bees of insecticides based on Endosulfan and Phosalon. Of interest in practice and for the official testing of pesticides are also the high pesticide sensitivity of old winter bees, the decrease in sensitivity of bees on a stable feed from early to late summer, and the sensitivity-reducing influence of pollen-rich food supply promoting development.It is important ecologically that pollens of different plant species vary in nutrient quality for the honey bee: there are perfectly worthless (conifers), poor-to-medium, and highly effective pollen types. As shown in this paper, these differences are relevant not only for the development of the physiological condition and breeding potential of the bee, but also for pesticide sensitivity. That bees gather worthless and poor-quality, sometimes even poisonous, pollen (some Ranunculus sp.) is evidently due to the phagostimulant present in all pollen types.

Silica, silicosis and lung-cancer: results from a cohort study in the stone and quarry industry

BACKGROUND

Workers compensated for silicosis outside the mining industry are at an increased risk of developing lung cancer. In the meta-analyses no data from Germany are involved. Furthermore, exposure data are necessary if a threshold value is to be assessed in order to reduce the risk for silicosis and also for lung cancer.

METHOD

A cohort study among workers compensated for silicosis between 1988 and 2000 from the stone and quarry industry in Germany has been initiated. The cohort was followed up until the end of 2001. From all workers a detailed description of their jobs was assessed.

RESULTS

Four hundred and forty workers were enrolled in the study. During the follow-up 144 workers died, compared with 74.35 expected cases based on the mortality rates of the general population from Germany, leading to a standard mortality ratio (SMR) of 1.94 (95% CI 1.63-2.28). Lung cancer was the cause of death in 16 cases (SMR 2.40; 95% CI 1.37-3.90). All workers had a peak exposure above 0.15 mg/m3, the current threshold value. The cumulative exposure was above 2 mg/m3.years and the average exposure was 0.10 mg/m3 or larger. No association between the exposure and the risk of developing lung cancer could be observed.

CONCLUSIONS

Workers from the stone and quarry industry compensated for silicosis are at an increased risk of developing lung cancer. In order to reduce that risk, the exposure has to be lowered, with a peak exposure below 0.15 mg/m3 and an average exposure below 0.10 mg/m3.

Telemedizinisch vernetzte Schlaganfallstationen

More than 100 stroke units have been established in Germany. In rural areas, however, acute stroke care needs to be improved. In order to advance clinical stroke therapy, two specialized stroke centers founded a telemedicine network (TEMPiS) among 12 community hospitals in eastern Bavaria. Each network hospital established specialized stroke wards where qualified teams manage acute stroke patients. Twenty-four hours daily, physicians in local hospitals are able to contact the stroke centers via videoconferencing including transmission of digital DICOM data. To study the efficacy of this network, a controlled trial will be performed. Five TEMPiS-network hospitals will be matched with five other hospitals equal in size, catchment area, and diagnostic techniques. For about 1 year, all consecutive stroke cases in the matched study hospitals will be prospectively recorded in a database. Neurological deficits will be quantified on the National Institute of Health Stroke Scale within 24 h after stroke onset. Mortality and institutional care as a combined primary endpoint will be assessed after 3 and 12 months. Furthermore, functional outcome according to the modified Rankin scale, Barthel score, and quality of life will be assessed using a standard telephone interview. Data acquisition started in July 2003, and final results are expected in 2005.

[The use of neuromuscular monitoring in Germany]

AIM

As there are no reliable epidemiological data for the use of muscle relaxants in Germany,we conducted a mailing study. The aim of the study was to compare the use of muscle relaxants between German anaesthesia departments. In the present part of the presentation we focused on neuromuscular monitoring (NMM) and management of residual paralysis.

METHODS

A total number of 2,996 questionnaires were sent to all registered anaesthesiological facilities in Germany and the return was 68.6% (2054 questionnaires).

RESULTS

In 574 of the returned questionnaires (28%) the regular use of NMM was confirmed. Intraoperative monitoring of neuromuscular block and assessment of neuromuscular recovery were the most frequent applications of NMM, i.e. 25% and 18% of returned questionnaires, respectively. Clinical signs, however, are still the most popular way to estimate the degree of neuromuscular blockade. Moreover, routine reversal at the end of surgery with a neostigmin/atropine mixture was not practiced in 75% of the anaesthesia departments.

CONCLUSIONS

This survey revealed that NMM is still very rarely used in daily clinical practice. Especially the seldom use of NMM to assess residual paralysis has to be improved.

[Application of muscle relaxants for rapid-sequence induction of anaesthesia]

The present study evaluates the use of muscle relaxants for rapid-sequence induction (RSI) and different application techniques (pre-curarisation, priming, timing) as a part of a nationwide survey in Germany. In 86.8% of anaesthesia departments succinylcholine is used for RSI and an average of 56.5% of respondents used only succinylcholine for RSI. Of all non-depolarising muscle relaxants rocuronium is the most frequently used alternative. Of the anaesthesia departments 2.6% use rocuronium regularly in patients with increased risk for aspiration of stomach contents; level one centres significantly more than others, 12.9% answered that pre-curarisation techniques were never used, whereas 45.6% use non-depolarising neuromuscular blocking drugs before giving succinylcholine in 80-100% of cases. Priming is not used by 64.4% of respondents, as opposed to 9.8% who utilise this technique regularly. The statements regarding timing are 71.1% and 5.4%, respectively. Alcuronium is used for RSI in departments in which the financial aspect is the primary decision criteria. Despite ist known side-effects and the on-going discussion over the past years, succinylcholine is still the most frequently used muscle relaxants for RSI. Priming is often declined by anaesthetists in Germany, most probably due to the absence of clear advantages and the possibility of severe complications. It is the opinion of the authors that timing but also drugs with a slow onset (e.g., alcuronium and Pancuronium) are obsolete in the context of RSI.

[The use of muscle relaxants for routine induction of anesthesia in Germany]

The aim of this study was to evaluate the use of muscle relaxants during induction of anesthesia in patients without risk of aspiration of stomach contents. Of the 2,996 questionnaires sent out, 2,054 (68.6%) could be analysed and the results show that succinylcholine is used regularly in 13.6% of anesthesia departments. The next most commonly used muscle relaxants are atracurium, vecuronium and mivacurium, followed by cis-atracrium, rocuronium and pancuronium. Alcuronium is the least frequently used muscle relaxant. During induction of an elective anesthesia procedure, a priming technique is used by 19% of anesthesiologists, 22% utilize precurarization, and a timing technique is performed in 7.1%. The use of muscle relaxants for on-going relaxation follows the same pattern as for induction of neuromuscular blockade and succinylcholine is used in 1.4% if further relaxation is needed. The desire for specific qualities of muscle relaxants is correlated with higher use of the specific substance: short onset time for rocuronium, good controllability with mivacurium, no side-effects with cisatracurium and economical aspects with alcuronium. Of the participants 76.6% voiced the desire for a non-depolarizing replacement for succinylcholine.Private practices use mivacurium more often than hospitals, level one hospitals use rocuronium and cisatracurium more often. This survey could not show a definite standard of use in terms of muscle relaxants for an elective case.Precurarization, priming and timing are used frequently in patients not at risk of aspiration. This should be reduced by on-going teaching.

[Application of muscle relaxants in Germany. A survey of German anaesthesia departments]

AIM

The aim of this study was to evaluate the use and application of muscle relaxants and neuromuscular monitoring in Germany.

METHODS

A total of 2,996 questionnaires were sent out to the heads of German anaesthesia departments and private anaesthesia practices. The questions covered frequency of muscle relaxants used,how they were used, and neuromuscular monitoring. Influences on the way muscle relaxants were used could be derived from the desire for specific properties of a muscle relaxant, the desire for different monitoring conditions and from the size of the institution. We correlated these features with application practice using logistic regression analyses.

RESULTS

Of the 2,996 questionnaires 2,058 could be analysed (68.6%). Amongst those were 102 level one hospitals (5%) and 903 private practices (44%). The replies from 350 (17%) departments were based on surveyed data, 1,613 (78.5%) were based on estimations. The desire for certain properties of muscle relaxants correlated with the use in practice, as were the desire for a non-depolarizing replacement for succinylcholine, the size of the department and the frequency of use of neuromuscular monitoring. Over 50% of all German anaesthesia departments limited the use of muscle relaxants to three. The use of laryngeal masks reduced the use of muscle relaxants.

CONCLUSIONS

The survey regarding use of muscle relaxants in Germany could for the first time give an overview on the use of anaesthesia-specific substances in Germany. From the different frequencies of use and use modalities,conclusions could be drawn towards a standard of application for the year 2000. Changes in this standard would raise the need for further trend surveys. The methods of statistical analysis and survey evaluation can be used as a base for further surveys.

Estimation of the general threshold limit values for dust

In 1997 the German MAK Commission set new general threshold limit values for dust. The procedure has recently been assessed (McLaughlin et al. 2001). One of the points raised was the use of inappropriate statistical methods. We want to address this point to a greater extent by discussing several alternatives implied by the already established threshold models, and we present results from a new approach that has been refined in the meantime: the use of the additive isotonic model. The underlined assumption of monotonicity regarding the dose-response relationship has been extensively investigated. One very flexible model, based on smoothing splines, shows in some of the samples a decline in the risk over a certain range of the exposure compared to the risk at baseline. Another approach with fractional polynomials and segmented regression lines shows that this result can be explained by chance. These methods show an increasing risk with increasing exposure. Additionally, permutation tests are used to prove the trend within the isotonic framework. The results from the additive isotonic model confirm previous assessments of the general threshold limit value.

Cardiovascular function of workers exposed to carbon disulphide

OBJECTIVES

The aim of the study was to verify that exposure to carbon disulphide (CS(2)) up to 10 ppm results in a negative inotropic effect on cardiovascular function.

METHODS

In a cross-sectional study a total of 325 workers exposed to CS(2) in the rayon-producing industry and 179 controls from the same plants were examined. The exposure assessment was based on personal air sampling and biological monitoring (2-thiothiazolidine-4-carboxylic acid (TTCA) in urine) for all persons. The examination consisted of a standardised questionnaire, physical examination, assessment of body fat mass, ergometric test with the determination of work capacity at heart rates of 100, 130, 150 and 170 beats/min, and electrocardiography.

RESULTS

The mean external exposure was 6.04 ppm CS(2) (range: 0.03-91.08); the mean internal exposure was 1.14 mg TTCA/g creatinine (range: 0.02-11.50). The workers exposed to CS(2) showed better physical fitness. The diameters of the left heart chamber of the exposed persons were not significantly different when compared with occupationally non-exposed workers, but there was a tendency of increasing diameters for the exposed employees. In the multiple linear regression the diameters showed physiologically plausible correlations with the body mass index, body fat mass, alcohol consumption, and physical fitness, but not, however, with the exposure, neither with the exposure group in all persons nor with the internal or external exposure within the exposed workers.

CONCLUSIONS

In this study, differences in the heart chamber diameters between exposed persons and controls could not be confirmed. Differences in physical fitness and constitution can explain differences in heart chamber diameters.

Accuracy of endoscopic ultrasonography in upper gastrointestinal submucosal lesions: a prospective multicenter study

BACKGROUND

Endoscopic ultrasonography (EUS) is commonly agreed to be the best imaging method for diagnosing and differentiating between submucosal lesions in the gastrointestinal tract. However, most of the current evidence for this derives from retrospective multicenter studies. A prospective multicenter analysis of the performance of EUS in diagnosing submucosal lesions in everyday practice was therefore conducted.

METHODS

Over a 2-year period, this study included 150 patients (52% men, mean age 59.8 years) from 23 centers who had a presumptive diagnosis of a submucosal lesion on upper gastrointestinal endoscopy. The patients' symptoms and EUS results were recorded. Endoscopic and endosonographic findings regarding lesion size, layer of origin, and the presumptive diagnosis (benign or malignant) were recorded. The reference methods used were surgery, biopsy, other imaging tests, and a follow-up period of 6 months.

RESULTS

Of the 150 patients, 102 had an intramural lesion (84 tumors, 18 other lesions such as cysts, aberrant pancreas, etc.), and 48 had an extraluminal compression--in most cases (n = 35) by normal organs or structures. For differentiating between a submucosal and an extraluminal compression, the sensitivity and specificity of endoscopy were 87% and 29%, whereas those of EUS were 92% and 100%. However, the sensitivity and specificity of EUS for differentiating between malignant and benign submucosal tumors were only 64% and 80%, respectively.

CONCLUSIONS

The accuracy of EUS in differentiating between submucosal tumors and extraluminal compressions is substantially superior to that of endoscopy, but EUS is still inadequate for differential diagnosis between benign and malignant submucosal tumors. However, EUS is still the best method of visualizing submucosal lesions precisely. The influence of EUS on the further management in these patients remains to be examined in subsequent studies.

Accuracy of endoscopic ultrasonography in upper gastrointestinal submucosal lesions: a prospective multicenter study

BACKGROUND

Endoscopic ultrasonography (EUS) is commonly agreed to be the best imaging method for diagnosing and differentiating between submucosal lesions in the gastrointestinal tract. However, most of the current evidence for this derives from retrospective multicenter studies. A prospective multicenter analysis of the performance of EUS in diagnosing submucosal lesions in everyday practice was therefore conducted.

METHODS

Over a 2-year period, this study included 150 patients (52% men, mean age 59.8 years) from 23 centers who had a presumptive diagnosis of a submucosal lesion on upper gastrointestinal endoscopy. The patients' symptoms and EUS results were recorded. Endoscopic and endosonographic findings regarding lesion size, layer of origin, and the presumptive diagnosis (benign or malignant) were recorded. The reference methods used were surgery, biopsy, other imaging tests, and a follow-up period of 6 months.

RESULTS

Of the 150 patients, 102 had an intramural lesion (84 tumors, 18 other lesions such as cysts, aberrant pancreas, etc.), and 48 had an extraluminal compression--in most cases (n = 35) by normal organs or structures. For differentiating between a submucosal and an extraluminal compression, the sensitivity and specificity of endoscopy were 87% and 29%, whereas those of EUS were 92% and 100%. However, the sensitivity and specificity of EUS for differentiating between malignant and benign submucosal tumors were only 64% and 80%, respectively.

CONCLUSIONS

The accuracy of EUS in differentiating between submucosal tumors and extraluminal compressions is substantially superior to that of endoscopy, but EUS is still inadequate for differential diagnosis between benign and malignant submucosal tumors. However, EUS is still the best method of visualizing submucosal lesions precisely. The influence of EUS on the further management in these patients remains to be examined in subsequent studies.

Accuracy of endoscopic ultrasonography in upper gastrointestinal submucosal lesions: a prospective multicenter study

BACKGROUND

Endoscopic ultrasonography (EUS) is commonly agreed to be the best imaging method for diagnosing and differentiating between submucosal lesions in the gastrointestinal tract. However, most of the current evidence for this derives from retrospective multicenter studies. A prospective multicenter analysis of the performance of EUS in diagnosing submucosal lesions in everyday practice was therefore conducted.

METHODS

Over a 2-year period, this study included 150 patients (52% men, mean age 59.8 years) from 23 centers who had a presumptive diagnosis of a submucosal lesion on upper gastrointestinal endoscopy. The patients' symptoms and EUS results were recorded. Endoscopic and endosonographic findings regarding lesion size, layer of origin, and the presumptive diagnosis (benign or malignant) were recorded. The reference methods used were surgery, biopsy, other imaging tests, and a follow-up period of 6 months.

RESULTS

Of the 150 patients, 102 had an intramural lesion (84 tumors, 18 other lesions such as cysts, aberrant pancreas, etc.), and 48 had an extraluminal compression--in most cases (n = 35) by normal organs or structures. For differentiating between a submucosal and an extraluminal compression, the sensitivity and specificity of endoscopy were 87% and 29%, whereas those of EUS were 92% and 100%. However, the sensitivity and specificity of EUS for differentiating between malignant and benign submucosal tumors were only 64% and 80%, respectively.

CONCLUSIONS

The accuracy of EUS in differentiating between submucosal tumors and extraluminal compressions is substantially superior to that of endoscopy, but EUS is still inadequate for differential diagnosis between benign and malignant submucosal tumors. However, EUS is still the best method of visualizing submucosal lesions precisely. The influence of EUS on the further management in these patients remains to be examined in subsequent studies.

Neoadjuvant chemotherapy followed by tumor debulking prolongs survival for patients with poor prognosis in International Federation of Gynecology and Obstetrics Stage IIIC ovarian carcinoma

BACKGROUND

Patients with advanced ovarian carcinoma of International Federation of Gynecology and Obstetrics (FIGO) Stage IIIC should be treated by radical surgical tumor debulking with the goal of complete tumor resection. Prolonged median survival can be achieved in those patients entirely free of tumor after surgery by the administration of postsurgical platinum/taxane-based chemotherapy regimens. However, residual tumor is present in the majority of patients, which limits survival prognosis. Different therapy approaches should be utilized to improve prognosis in these patients. Neoadjuvant chemotherapy could induce "downstaging" of the tumor and thus improve operability. Here, evidence of large ascites volume (>500 mL) can be used to identify those patients who could benefit from neoadjuvant chemotherapy.

METHODS

In a prospective, nonrandomized Phase II study, 31 patients with advanced FIGO Stage IIIC ovarian carcinoma and large ascites volume (>500 mL) received 3 cycles of platinum/taxane-based combination chemotherapy, followed by tumor debulking surgery and 3 additional cycles of platinum/taxane-based combination chemotherapy. During the same period, 32 patients with advanced FIGO Stage IIIC ovarian carcinoma and large ascites volume (>500 mL) received conventional therapy (tumor debulking surgery followed by 6 cycles of platinum/taxane-based combination chemotherapy). The two groups were investigated and compared with respect to tumor resection rates, blood transfusion requirements, morbidity, and mortality during surgery, duration of surgery, and median survival.

RESULTS

The tumor resection rate in the patient group receiving neoadjuvant chemotherapy was significantly higher (P = 0.04) than that of the conventionally treated group; the median survival time of 42 months versus 23 months also was significantly longer (P = 0.007). Time spent in surgery, blood transfusion requirements, morbidity, and mortality during surgery were not significantly different.

CONCLUSIONS

Patients with advanced ovarian carcinoma of FIGO Stage IIIC who will benefit only marginally from conventional therapy can be identified by evidence of large ascites volume. Higher tumor resection rates and longer median survival can be achieved in these patients by the use of neoadjuvant chemotherapy. A prospective randomized multicenter study currently is being performed by the Society for Gynecological Oncology in Germany to confirm these findings.

Neoadjuvant chemotherapy followed by tumor debulking prolongs survival for patients with poor prognosis in International Federation of Gynecology and Obstetrics Stage IIIC ovarian carcinoma

BACKGROUND

Patients with advanced ovarian carcinoma of International Federation of Gynecology and Obstetrics (FIGO) Stage IIIC should be treated by radical surgical tumor debulking with the goal of complete tumor resection. Prolonged median survival can be achieved in those patients entirely free of tumor after surgery by the administration of postsurgical platinum/taxane-based chemotherapy regimens. However, residual tumor is present in the majority of patients, which limits survival prognosis. Different therapy approaches should be utilized to improve prognosis in these patients. Neoadjuvant chemotherapy could induce "downstaging" of the tumor and thus improve operability. Here, evidence of large ascites volume (>500 mL) can be used to identify those patients who could benefit from neoadjuvant chemotherapy.

METHODS

In a prospective, nonrandomized Phase II study, 31 patients with advanced FIGO Stage IIIC ovarian carcinoma and large ascites volume (>500 mL) received 3 cycles of platinum/taxane-based combination chemotherapy, followed by tumor debulking surgery and 3 additional cycles of platinum/taxane-based combination chemotherapy. During the same period, 32 patients with advanced FIGO Stage IIIC ovarian carcinoma and large ascites volume (>500 mL) received conventional therapy (tumor debulking surgery followed by 6 cycles of platinum/taxane-based combination chemotherapy). The two groups were investigated and compared with respect to tumor resection rates, blood transfusion requirements, morbidity, and mortality during surgery, duration of surgery, and median survival.

RESULTS

The tumor resection rate in the patient group receiving neoadjuvant chemotherapy was significantly higher (P = 0.04) than that of the conventionally treated group; the median survival time of 42 months versus 23 months also was significantly longer (P = 0.007). Time spent in surgery, blood transfusion requirements, morbidity, and mortality during surgery were not significantly different.

CONCLUSIONS

Patients with advanced ovarian carcinoma of FIGO Stage IIIC who will benefit only marginally from conventional therapy can be identified by evidence of large ascites volume. Higher tumor resection rates and longer median survival can be achieved in these patients by the use of neoadjuvant chemotherapy. A prospective randomized multicenter study currently is being performed by the Society for Gynecological Oncology in Germany to confirm these findings.

[Morphological findings and medical insurance aspects in 371 exhumations]

OBJECTIVES

The morphological findings in organ systems following exhumation, form the basis for answering a number of medical insurance issues. The aim of this study was to analyse the development of the number of exhumations performed and the medical insurance relevance over a 31-year-period.

METHODS

A total of 371 exhumations, performed between 1967-1998 at the Institute of Pathology, Occupational Associations Hospital, Bochum, for medical insurance reasons were evaluated.

RESULTS

The average number of days after burial was 74, ranging from 9 to 47.8. For the first third of the period investigated, the proportion of exhumations was 3.5% of all autopsy cases, for the second third this fell to about 0.4% and rose to 1.5% for the last third. In the first two-thirds, the main reasons for the exhumations were related to the grading and effects of pneumoconioses in connection with the cause of death. In the last third, asbestos-associated diseases were mainly involved. In 99.2% of all cases, the autopsy results revealed important evidence for clarification of the medical insurance issues. The current catalogue of expectations listing the pathomorphological findings which can be expected after certain periods of internment, could be extended by our own results.

Restenosis after coronary placement of various stent types

Coronary stent implantation is being performed in an increasing number of patients with a wide spectrum of clinical and lesion characteristics. A variety of stent designs are now available and continuous efforts are being made to improve the stent placement procedure. The objective of this study was to perform a comprehensive analysis of the relation between clinical, lesion, and procedural factors, and restenosis after intracoronary stenting in a large and unselected population of patients. A consecutive series of 4,510 patients with coronary stent placement was analyzed. Exclusion criteria were only a failed procedure and an adverse outcome within the first month after the intervention. Follow-up angiography was performed in 80% of patients at 6 months. Clinical, lesion, and procedural data from all 3,370 patients (4,229 stented lesions) with follow-up angiography were analyzed in a logistic regression model for restenosis (> or =50% diameter stenosis). Clinical factors contributed to the predictive power of the model much less than lesion and procedural factors. The strongest risk factor for restenosis was a small vessel size, with a 79% increase in the risk for a vessel of 2.7 mm versus a vessel of 3.4 mm in diameter. Stent design was the second strongest factor; the incidence of restenosis ranged from 20.0% to 50.3% depending on the stent type implanted. In conclusion, this study demonstrates the predominant role of lesion and procedural factors in determining the occurrence of restenosis after coronary stent placement. Among these factors, stent design appears to play a particularly important role in the hyperplastic response of the vessel wall.

Randomized trial of cefotiam prophylaxis in the prevention of postoperative infectious morbidity after elective cesarean section

A prospective, randomized study was performed in order to evaluate the effect of cefotiam in the prevention of postoperative infectious morbidity in patients undergoing low-risk elective cesarean section. A total of 146 patients were randomly assigned to receive either intraoperative single-shot prophylaxis with 2 g cefotiam (study group, n =76) or no prophylaxis (control group, n=70). Due to a higher rate of urinary tract infections, the incidence of infectious morbidity after cefotiam prophylaxis was higher in the study group than in the control group (16% vs. 9%, P=0.1). Postoperative infectious morbidity following low-risk elective cesarean section cannot be reduced by intraoperative cefotiam prophylaxis.