Maßnahmen zur Qualitätsförderung in der Arztpraxis

best practice onkologie -     

Supportive Maßnahmen der Komplementärmedizin

When controlling symptoms in malignant diseases, complementary therapies can make important contributions. This is demonstrated in several important and/or frequent symptoms in cancer patients. Complementary therapies should supplement but not replace established treatments and can be useful, especially where no other established procedures are available. Treatments involve herbal applications as well as acupuncture and so-called mind-body techniques. As information on tumor patients is sometimes insufficient, extrapolation from experiences with other diseases may be helpful, at least as far as side-effects are concerned. Possible drug interactions must be kept in mind especially with herbal treatments.     

Mißverständnisse bei der Aufklärung von Tumorpatienten

Ein wichtiges Prinzip in der Betreuung von Tumorpatienten in den westlichen L?ndern stellt der sogenannte “Informed-Consent” dar. Nach Aufkl?rung auf der Basis der verfügbaren notwendigen Informationen wird dabei vom Patienten erwartet mitzuentscheiden, welche Therapie und welches therapeutische Ziel für ihn am besten sei. Insbesondere in der Onkologie sind die zu treffenden Entscheidungen jedoch h?ufig von der hohen emotionalen Belastung gepr?gt, die mit der Diagnose “Krebs” verbunden ist, und sie beinhalten individuell schwer zu verarbeitende Aspekte wie den Umgang mit statistischen Angaben zu Wahrscheinlichkeiten für Ansprechraten, überlebenszeit-Verl?ngerung oder Heilung. Eine aktuelle Arbeit aus Australien hat in diesem Kontext n?her untersucht, welche Inhalte die Patienten im Rahmen der Aufkl?rung wirklich verstehen.     

Isolierte Extremitätenperfusion zur lokalen Tumorkontrolle an den Gliedmaßen

Clear and wide safety margins are required in surgical resections of high-grade soft tissue sarcomas (STS) due to the proliferation patterns at the periphery of the tumors. But resections of large and deep-seated tumors are often limited by close or even marginal resection margins in order to salvage a limb and its function. Hence, neoadjuvant treatment strategies may improve subsequent surgical resection by shrinking and devitalizing the local tumor. Of these treatment modalities, hyperthermic isolated limb perfusion with TNF-α and melphalan (TM-ILP) provides the most effective deterioration of advanced and even nonresectable STS by immediate destruction of the vasculature. Different studies have reported remission rates of up to 80%, with improved subsequent resection as well as minimization of the surgical trauma usually associated with the resection of high-grade sarcomas. Obviously, TM-ILP has its greatest potential in advanced STS of the limbs with concomitant metastatic disease. Patients are ready for systemic treatment strategies within days of deterioration of the local tumor by TM-ILP. This treatment modality should be offered to these patients and should be available in tertiary cancer centers.     

Die Rolle der Fachgesellschaften zur Realisierung einer interdisziplinären Onkologie

Medical societies in Germany have a different understanding of their roles. Because health care systems today are influenced by political conditions, it is inevitable that traditional medical societies will develop into organizations that actively contribute their expertise to daily health care. In oncology, this concerns the implementation of an interdisciplinary treatment approach.     

Die Berechnung von Konversionsfaktoren für den Strahlenschutz bei äußerer Strahlenexposition

Calculations are essential for radiation protection practice because organ doses and effective doses cannot be measured directly. Conversion coefficients describe the numerical relationships of protection quantities and operational quantities. The latter can be measured in practical situations using suitable dosimeters. The conversion coefficients are calculated using radiation transport codes - usually based on Monte Carlo methods - that simulate the interactions of radiation with matter in computational models of the human body. A new generation of human body models, the so-called voxel models, are constructed from image data of real persons using suitable image processing systems, consequently, they represent the human anatomy more realistically than the so-called mathematical models. The numerical effects of realistic body anatomy on the calculated conversion coefficients can amount to 70 % and more for external exposures.     

G-CSF zur Prophylaxe der Neutropenie und der febrilen Neutropenie,Anämie bei Krebserkrankung

best practice onkologie - Infektionen bei neutropenischen Patienten nach Chemotherapie manifestieren sich meistens durch Fieber (febrile Neutropenie, FN). Zu den wichtigsten Determinanten des...     

Bildqualitätseinbußen bei der Bildausgabe eines digitalen Röntgenaufnahmesystems

Not all digital radiography systems allow an unrestricted image postprocessing for the radiologist. Depending on the X-ray system there are restrictions in varying brightness and contrast of the image. We compared grey level information that are given to the radiologist by various digital radiography systems. Histograms of differently postprocessed X-ray images were calculated, which were acquired by three different X-ray systems. We found that every modality has its own way of saving and converting the images into DICOM data. The processed image is either sent into PACS with the initial grey level range (10 or 12 bit) or the image is sent with a reduced grey level range due to windowing. The grey level range is associated with the ability of unrestricted windowing in PACS. So, taking an image with a reduced grey level range, the radiologist will face limited potential to optimise the window setting individually afterwards. The loss of image quality due to image transfer from the modality to PACS can lead to an information loss in the diagnostic relevant range.     

Nutzung von Krebsregisterdaten zur Messung der Qualität in der klinischen Onkologie und für Versorgungsforschung

Background

The routine care of cancer patients differs from the setting of randomized controlled clinical trials. In routine care patients of all age groups are treated and often suffer from multiple comorbidities, therefore results from clinical trials cannot always be directly applied to the routine care setting. The aim of this review is to collate the clinical cancer registry data regarding questions of quality of care and health services research. By the implementation of the further development of the early detection of cancer and quality assurance through clinical cancer registries Act (KFRG §65c Social Code V, SGB V) in 2013 the gap between the results from clinical trials and comprehensive routine care settings will be filled and the “last mile” (H. Pfaff) with the many facets of quality of process and results will be reflected by healthcare research.

Objective

The instruments necessary to collate, combine and evaluate the quality of oncological treatment according to clearly defined questions, are systematic documentation and analysis of the routine care setting. This report gives an introduction to the methodology of cancer registries and shows which types of questions can be investigated with such register data based on two examples.

Methods

Outcome data from nationwide clinical cancer registries were collected and are presented according to existing quality indicators from the guidelines on treatment quality. The distribution and survival benefit of stage II colon cancer patients were reviewed based on the quality indicators for the number of lymph nodes examined nationwide (12 or more lymph nodes should be removed and examined). Similarly, the outcome of adjuvant chemotherapy in patients with stage II colon cancer is presented using a population-based regional cancer registry.

Results

The nationwide analysis of the quality indicators showed a significantly better survival for patients when more than 12 lymph nodes were removed and examined than for patients when less than 12 lymph nodes were removed. In the regional analysis patients with stage II colon cancer and T4 tumors showed a significantly benefit from adjuvant chemotherapy. This report identifies ways in which register data for the measurement of the quality of treatment and for health services research can be utilized.

     

Qualitätskriterien für Meßsonden zur intraoperativen Lokalisation Tc99m-markierter Lymphknoten

Based on the Sentinel Lymph Node (SLN) concept of malignant melanoma [11] an increasing number of γ-probe guided sentinel lymphadenectomies is performed. Therefore a steadily growing number of commercially available probe systems is presented. Quality control criteria and hints for choosing the appropriate system are defined. Several systems of different manufacturers were tested and their characteristics were determined.     

Dosismonitorvorwahl für ein neues Film-Folien-System zur Qualitätskontrolle in der Strahlentherapie

The film-screen-system Kodak EC-L allows verification with higher contrast than conventional systems. This advantage is accompanied by a loss of dynamic range. The monitor units show more limitations than in the case of conventional films. A procedure is required to find the optimal monitor units for verification. For photon energies of 5, 8, and 16 MV the necessary monitor units (MU) for an optical density of 1.0 have been measured. Solid water phantoms of thickness (PD) 10, 25 and 40 cm have been used. Focus-film-distance (FFA), phantom-film-distance (PFA) and field size (FG) have been varied. Monitor units at low phantom-film-distance and phantom thickness of 10 cm proved to be almost energy-independent. Effect of focus-field-distance can be approached by an inverse square law. Phantom-scattering contributions influenced the necessary monitor units especially at low energies, small phantom-film-distances and large fields. The dependence of energy, field size, phantom-film-distance and focus-film-distance can be described easily by a heuristic formula. It can be used to provide exposure-tables.     

Chirurgische Maßnahmen zur Symptomlinderung bei Tumorschmerz

Surgery plays an important role in the symptom control of tumor diseases for therapy with curative and also palliative intentions. Especially by palliative indications the decisive target criterion is a beneficial influence on the tumor-associated symptoms such as pain, functional limitations and obstipation and therefore on the quality of life. There are specific areas of application for palliative operations for nearly all tumor forms and symptoms. The decision regarding the indications must consider the available alternatives and carefully weigh up the options as well as the limits and the burden caused by the procedure in each individual case. This necessitates a special expertise and a good interdisciplinary cooperation between the disciplines involved. The highest demands are placed on the surgeon with respect to the quality of the decisions and the operative implementation.     

Strahlenexposition der Patienten bei pädiatrischen Herzkatheteruntersuchungen Teil 2: Patientenbezogene Meßergebnisse

Age, entire exposure duration and dose-area products for pa and lat beam as well as the number of angiographies have been recorded for 2114 pediatric cardiac catheterizations within the time period 1982 to 1996. Furthermore the average field dimensions and sizes at the patient entrance surface for pa and lat beams and the frequency distributions for dose-area product rates, the entire dose-area products and the effective doses, calculated by means of age class dependent conversion factors, are given for all patients. The effective doses for new-borns are higher by about a factor 2 (Q₅₀ = 6.5 mSv compared to 3.0 mSv) compared to children of higher age class, despite of the quite smaller body dimensions and thus smaller dose-area product rates. Cancer risks by radiation exposure are significantly higher for new-borns than for elder children for the same effective dose. Although no age specific factor can be given it is possible to derive from literature data, that cardiac catheterizations cause radiation risks, which are larger at least by a factor 2 to 4 with decreasing age, especially for thyroid and breast cancer (the latter more for girls).     

Empfehlungen zur Verlaufskontrolle und Zweitlinientherapie bei der chronischen myeloischen Leukämie (CML)

The prognosis for patients with chronic myeloid leukemia (CML) is dependent on the degree of remission achieved within a specific time frame. Regular assessments are necessary for early recognition of patients with suboptimal response or treatment failure, so that the therapeutic strategy can be adapted accordingly. Despite the impressive results obtained with imatinib some patients in the chronic phase will require an alternative therapy during the course of treatment. In the case of imatinib failure or intolerance, the tyrosine kinase inhibitors nilotinib and dasatinib are approved second-line therapies and both are highly effective. The choice of which agent to select as the optimal second-line therapy should be based on individual patient status, the different side-effect profiles of these two agents and the different efficacies in the presence of specific BCR-ABL mutations. In the case of imatinib failure allogeneic stem cell transplantation should also be considered as a therapeutic option. This article discusses current recommendations on monitoring frequency and methods in CML as well as differences between nilotinib and dasatinib, which can guide clinicians in selecting an optimal second-line therapy.     

Pflegerische Maßnahmen in der Radioonkologie

Die Radioonkologie nimmt in der kurativen und palliativen Behandlung onkologischer Patienten einen wichtigen Stellenwert ein. Moderne Therapie- und Fraktionierungskonzepte haben zu einer wesentlichen Verbesserung der Heilungschancen beigetragen. Das Ausma? der subjektiv beeintr?chtigenden akuten und sp?ten Nebenwirkungen, insbesondere der Haut- und Schleimhaut, bestimmen wesentlich die Akzeptanz der Behandlung durch die Patienten. Durch therapiebegleitende pflegerische Ma?nahmen ist eine Linderung der Beschwerdesymptomatik und teils auch eine Verringerung des Auspr?gungsgrades sp?ter Reaktionen m?glich. Hierfür stehen verschiedene Konzepte ?hnlicher Wertigkeit zur Verfügung. Eine Empfehlung zu pflegerischen Ma?nahmen in der Radioonkologie wird exemplarisch im Tübinger Pflegekonzept gegeben.     

Immuntherapeutische Ansätze zur Behandlung von Leukämien

Zusammenfassung Das adaptive Immunsystem (B-Zellen und T-Zellen) hat Rezeptoren, die mit großer Variabilität eine nahezu unbegrenzte Anzahl spezifischer Pathogene erkennen können und zu einem immunologischen Gedächtnis führen. Obwohl das Immunsystem sich entwickelt hat, um Selbst und Nicht-Selbst zu diskriminieren, ist es in der Lage, die maligne Transformation von Selbst, d. h. bösartige Zellen, zu überwachen. Humanisierte monoklonale Antikörper binden an Leukämieantigene und führen zur antikörperabhängigen Zytoxizität in vivo. Leukämieassoziierte Peptidantigene werden von T-Zellen erkannt und bilden die Grundlage für therapeutische Vakzinierungsstrategien bei Patienten mit Leukämien.