Die Rolle der Selbsthilfegruppen in der Onkologie

Background

Little is known about self-help associations and their possibilities. Obstacles often prevent early contacts between affected people.

Objectives

The psychosocial support given by self-help associations in different phases is evaluated.

Materials and methods

Based on the experience of the Deutsche ILCO and from cooperation with other organizations and institutions, various dimensions of self-help groups are investigated.

Results

On the professional side, there is a lack of knowledge and of attitude. Suitable structures are rare.

Conclusions

The removal of barriers and development of effective structures are overdue.

     

Do-it-yourself Artificial Pancreas – Technologiehype oder realer Nutzen?

Background

Most type 1 diabetes mellitus patients are not capable of achieving close to normal glucose levels and thus face a constant risk of severe hypoglycemia and diabetic ketoacidosis.

Objectives

Patients develop their own personal non-approved medical devices to compensate for gaps in the existing medical technology.

Materials and methods

Current studies are assessed and basic work and challenges are discussed.

Results

The authorization of such systems from patients themselves results in the development of medical devices suitable for use but approved only based on freely available algorithms. Legal framework conditions, lack of standards on the interoperability of medical devices and uncertainties about future technology trends are giving rise to ongoing controversies.

Conclusions

There is a need to validate these new approaches, agree upon success criteria and provide solid evidence of their effectiveness.

     

Immunmodulierende Wirkung von Vitamin D und Typ-1-Diabetes

Objective

Vitamin D is not only essential for bone metabolism, but also has an additional immune-modulating effect on the immune system, which may play a role in the pathogenesis of several endocrine diseases.

Aim

In this review, we debate the effects and recommendations of vitamin D supplementation, especially in the context of the nonclassical effects.

Results

Evidence from animal model and epidemiological studies supports a role for vitamin D in many endocrine conditions. Vitamin D supplementation may play a role in the prevention of type 1 diabetes mellitus.

Conclusions

Although observational studies support a potential role of vitamin D in endocrine disease, high-quality evidence from clinical trials to establish a place for vitamin D supplementation in optimizing endocrine health are lacking. Based on observational studies, vitamin D deficiency should probably be avoided in individuals at high risk of developing type 1 diabetes, specifically in early life.

     

Diabetes und Depression

Background

One of four patients with type 2 diabetes mellitus (T2DM) has clinically relevant depression. On the other hand, depression increases the risk for T2DM as well as micro- and macrovascular complications.

Objectives

This association may reflect a shared pathophysiology consisting of complex bidirectional interactions, which may influence therapy and prognosis.

Materials and methods

Recent findings, reviews and basic literature are analysed and an update is presented and discussed.

Results

Overall, accumulating evidence indicates a metabolic–mood syndrome with a linkage that includes stress sensitivity, insulin resistance (IR), neurohormonal dysregulation and inflammation. IR alters dopamine turnover and causes depression-like behaviour. Furthermore IR is associated with worse memory performance. Metabolic risk influences neurodevelopment. However, cross-sectional data do not support a genetic association between T2DM and depression.

Conclusions

T2DM may promote depression and interact with neurodevelopment and neurodegeneration. Comorbidity seems to be particularly toxic. Both prevention of T2DM in depressed patients and treatment of depression in T2DM are of considerable significance. Serotonin reuptake inhibition (SSRI) and psychotherapy are effective in the treatment of depression.

     

Radiologische Diagnostik der Sigmadivertikulitis und Stadieneinteilung

Background and objectives

Radiological imaging is of central importance for diagnosing acute and chronic diverticular disease. The indications for the various radiological imaging modalities and their most important findings are discussed in this review article.

Methods

The current literature on this topic was reviewed and summarized.

Results

Contrast-enhanced computed tomography of the abdomen is the method choice in cases of suspected acute diverticulitis and should enable a differentiation between complicated and uncomplicated forms. In suspected chronic diverticular disease virtual colonoscopy represents an equivalent alternative to classical colonoscopy.

Conclusion

Based on imaging findings therapeutic decisions can be made and the radiological findings can have some prognostic value in the follow-up of patients.

     

Interdisziplinäre Therapie kolorektaler Lebermetastasen

Background

Liver metastases occur in every second patient with colorectal carcinoma.

Objectives

Therapeutic options for patients with hepatic metastases from colorectal cancer (CRC), specific indications, and interdisciplinary concepts are presented.

Methods

Based on the current literature and guidelines, novel study results and expert opinions are discussed.

Results

Surgical resection of primarily resectable liver metastases from CRC is standard and allows long-term control or healing in up to 36?% of cases. Adjuvant chemotherapy after resection can be performed, but the current study data are insufficient to generally recommend perioperative chemotherapy in this setting. Secondary resectability of primarily irresectable metastases can be reached by interventional induction of liver hypertrophy or neoadjuvant chemotherapy (conversion therapy). New study results suggested a benefit for more intensive combination chemotherapies, but possible side effects have to be considered. Finally, locoregional ablative therapies have gained increasing importance in the multimodal treatment of hepatic CRC metastases, and current clinical trials suggest a possible benefit of combination strategies together with chemotherapy and surgery even in early therapy lines.

Conclusions

Liver metastases from CRC require an multidisciplinary approach. Therefore, patients should be presented to a multidisciplinary tumor board not only at the beginning, but also along different therapy lines.

     

Digitalisierung in der alltäglichen Praxis

Background

The digitization of medicine in clinical practice as well as the digitization and the use of diabetes technologies has been an exciting and sometimes difficult process for a variety of reasons. Although establishing technologies in medical practice is helpful, it also means work associated with convincing others regarding this, whereby less work is needed to convince our patients.

Aim of the article

Using the example of our diabetological endocrinological outpatient clinic, we want to show which hurdles had to be overcome and which advantages we see from a digital orientation.

Conclusion

By using diabetes technologies, we see clear benefits of more individualized therapy. So-called “talking medicine” has come more into the foreground and the data gained from this technology support this claim of individualized medicine.

     

Spätfolgen einer Krebsbehandlung im Kindes- und Jugendalter

Background

Childhood cancer survivors are at risk of cancer- and treatment-related chronic health conditions. Since these sequelae may occur years after the end of treatment, many patients are already adults and have completed pediatric oncological care. Thus, successful transition is essential in order to ensure long-term surveillance.

Objectives

The present review outlines the most frequent late effects of childhood cancer treatment. Moreover, difficulties in transition of these patients are discussed and interdisciplinary models of care are presented.

Results

Late effects following childhood cancer treatment occur in over two thirds of patients 30 years after the end of the oncological treatment and can affect different organs. The most frequent sequelae are endocrine disturbances, cardiac conditions, and subsequent neoplasms. Many late effects are effectively manageable if detected early. This necessitates an interdisciplinary approach as well as life-long surveillance.

Conclusions

Transition from pediatric to internal medicine care as well as a change in the focus of care, shifting from relapse centered follow-up to late-effects centered surveillance, constitute a special challenge for a successful transition of long-term childhood cancer survivors. Specialized late-effects survivorship clinics offering interdisciplinary care from pediatric oncologists, specialists of internal medicine, and further disciplines enable the early diagnosis and treatment of late-effects.

     

Gallengangatresie und angeborene Cholestasesyndrome

Background

A growing number of patients with biliary atresia and congenital cholestatic syndromes are reaching adulthood. These patients often have a number of typical medical features, including specific characteristics of liver transplantation medicine.

Objective

What are the special features in the care of adults suffering from liver diseases with manifestation in childhood and adolescence, both before and after liver transplantation (LTX). How does the progression of individual diseases differ depending on age at manifestation? What are specific aspects following pediatric LTX?

Patients and methods

Evaluation and discussion of existing guidelines and recommendations of the individual disciplines and professional societies as well as the current literature. Joint discussion of the recommendations between disciplines (gastroenterology, pediatric gastroenterology, surgery). Inclusion of center-specific experiences with transition from existing transition outpatient departments and training.

Results

The recommendations are presented specifically for each disease. Special features in individual diseases after LTX are also discussed. Diagnosis-independent general treatment concepts for cholestasis and chronic liver disease are presented.

Conclusion

Patients with biliary atresia and congenital cholestatic syndromes have a life-long chronic liver disease with and without LTX and require specific medical care. The patients benefit from the pooling of expertise in the individual disciplines.

     

Bedeutung des Stillens für diabetische Mütter und ihre Kinder

Background

Exclusive breastfeeding provides optimal nutrition and health protection for mothers and their offspring.

Health benefits of breastfeeding for diabetic women

Diabetic mothers who breastfeed in the first 4 months postpartum have improved metabolic parameters, e.g., lower blood lipids, lower blood glucose, and greater insulin sensitivity. Studies have reported that longer duration of breastfeeding in women with a history of gestational diabetes may reduce long-term risks of cardiometabolic disease, including type 2 diabetes.

Health benefits of breastfeeding for children

Children of diabetic mothers may benefit from breastfeeding in that they have lower rates of hypoglycemia immediately after birth and lower rates of obesity in later life. It has been suggested that the latter benefits may only be observed if breastfeeding is continued beyond a certain period where breastmilk composition would have normalized over time.

Conclusion

Due to several risk factors and pathophysiological mechanisms, diabetic women are less likely and for a shorter duration to breastfeed. Therefore, diabetic women should be encouraged to breastfeed exclusively for at least 4–6 months to improve maternal and child morbidity, to prevent noncommunicable diseases in later life, and to decrease health care costs.

     

Highly Effective Cystic Fibrosis Clinical Research Teams: Critical Success Factors

BACKGROUND

Bringing new therapies to patients with rare diseases depends in part on optimizing clinical trial conduct through efficient study start-up processes and rapid enrollment. Suboptimal execution of clinical trials in academic medical centers not only results in high cost to institutions and sponsors, but also delays the availability of new therapies. Addressing the factors that contribute to poor outcomes requires novel, systematic approaches tailored to the institution and disease under study.

OBJECTIVE

To use clinical trial performance metrics data analysis to select high-performing cystic fibrosis (CF) clinical research teams and then identify factors contributing to their success.

DESIGN

Mixed-methods research, including semi-structured qualitative interviews of high-performing research teams.

PARTICIPANTS

CF research teams at nine clinical centers from the CF Foundation Therapeutics Development Network.

APPROACH

Survey of site characteristics, direct observation of team meetings and facilities, and semi-structured interviews with clinical research team members and institutional program managers and leaders in clinical research.

KEY RESULTS

Critical success factors noted at all nine high-performing centers were: 1) strong leadership, 2) established and effective communication within the research team and with the clinical care team, and 3) adequate staff. Other frequent characteristics included a mature culture of research, customer service orientation in interactions with study participants, shared efficient processes, continuous process improvement activities, and a businesslike approach to clinical research.

CONCLUSIONS

Clinical research metrics allowed identification of high-performing clinical research teams. Site visits identified several critical factors leading to highly successful teams that may help other clinical research teams improve clinical trial performance.

     

Establishing a General Medical Outpatient Clinic for Cancer Survivors in a Public City Hospital Setting

INTRODUCTION

Many cancer centers and community hospitals are developing novel models of survivorship care. However, few are specifically focused on services for socio-economically disadvantaged cancer survivors.

AIMS

To describe a new model of survivorship care serving culturally diverse, urban adult cancer patients and to present findings from a feasibility evaluation.

SETTING

Adult cancer patients treated at a public city hospital cancer center.

PROGRAM DESCRIPTION

The clinic provides comprehensive medical and psychosocial services for patients within a public hospital cancer center where they receive their oncology care.

PROGRAM EVALUATION

Longitudinal data collected over a 3-year period were used to describe patient demographics, patient needs, and services delivered. Since inception, 410 cancer patients have been served. Demand for services has grown steadily. Hypertension was the most frequent comorbid condition treated. Pain, depression, cardiovascular disease, hyperlipidemia, and bowel dysfunction were the most common post-treatment problems experienced by the patients. Financial counseling was an important patient resource.

DISCUSSION

This new clinical service has been well-integrated into its public urban hospital setting and constitutes an innovative model of health-care delivery for socio-economically challenged, culturally diverse adult cancer survivors.

     

Transanal endoscopic microsurgical submucosa dissection in the treatment of rectal adenomas and T1 rectal cancer

Background

The treatment of flat rectal adenomas is challenging. The technical difficulty and the potential of malignancy in suspected benign lesions are the factors in question. Surgical and interventional endoscopic techniques are implemented in Europe without a clear strategy. To minimize recurrent adenoma and unclear histopathological work up en bloc excision is desirable.

Methods and results

We demonstrate in this article the transanal endoscopic microsurgical submucosa dissection (TEM-ESD) procedure as a feasible method for en bloc excision of rectal adenomas and early rectal cancer. The surgical technique is demonstrated in detail with the help of a video of the operation that is available online. The results of a consecutive series of 78 patients are presented.

Conclusion

TEM-ESD is a safe procedure for resection of rectal adenomas and low risk carcinomas. It offers the possibility of organ preservation and minimizes functional disturbances. In case of a necessary salvage operation, the preserved integrity of the rectal muscle tube grants maximal oncological safety.

     

Surgical aspects of atrial arrhythmia

Background

Atrial arrhythmias are frequently described in congenital heart disease.

Objectives

To provide a surgical perspective of anti-arrhythmic procedures and strategic approaches.

Methods

Discussion of the history of anti-arrhythmic treatments in congenital heart disease.

Results

Before the advent of the Maze procedure (first published in 1991), surgery mainly focused on patients with Wolff–Parkinson–White syndrome and also on arrhythmias in Ebstein’s malformation. Atrial septal defects (ASD) subsequently received more attention, i.e., in terms of atrial arrhythmia in the natural prognosis and the surgically modified course and in terms of surgical versus transcatheter approaches. Based on the background of various atrial arrhythmia mechanisms of ASD, several surgical procedures have been reported, ranging from the bilateral full Maze procedure to simple modification of right atriotomy. The so-called right atrial Maze procedure occupies a special position from the viewpoint of cardiology in acquired heart disease, especially in cases of frequently occurring right heart failure. In hearts with more complex structural abnormalities, a detailed understanding of the conditions to improve overall surgical outcome and develop future “anti-arrhythmic” strategies is necessary.

Conclusions

It is important to precisely specify factors in the individual cases, not only morphological diversity but also technical and strategic variations and their consequences. A variety of anti-arrhythmic surgical procedures are currently available. How and when to use which procedure requires professional insight and cautious clinical decision-making.

     

Nichtalkoholische Steatohepatitis und ihre Folgen

Background

The prevalence of nonalcoholic fatty liver disease (NAFLD) continues to increase. An estimated 25?% of the adult population worldwide and more than 50?% of patients with type 2 diabetes or obesity have NAFLD.

Objectives

An overview of the natural history and complications of NAFLD is provided.

Materials and methods

Following an extensive literature research, the current guidelines, expert opinions and studies focusing on NAFLD were analyzed.

Results

The term NAFLD includes the entities nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH), which are defined by histological parameters. Importantly, “benign” NAFL may progress towards more aggressive NASH with the development of liver fibrosis. The grade of fibrosis is the most important predictor for overall and liver-related mortality in NAFLD patients and patients suffering from type 2 diabetes mellitus have a higher risk for progressive fibrosis. Progressive NAFLD can develop into liver cirrhosis with the potential of fatal complications of portal hypertension and liver failure. Notably, hepatocellular carcinoma may also develop in noncirrhotic NAFLD. Furthermore, NAFLD is an independent risk factor for cardiovascular disease and extrahepatic malignancy, which represent the two most frequent causes of death in NAFLD patients. To date, a lifestyle intervention aiming at weight reduction and increased physical activity is the first-line therapy for NAFLD.

Conclusions

NAFLD is one of the most common liver diseases and is associated with relevant hepatic and extrahepatic morbidity and mortality.

     

Hepatogener Diabetes

Background

Disturbances of glucose metabolism are common in chronic liver disease and about 30–40?% of patients with liver cirrhosis develop type 2 diabetes. The diabetes may be a direct consequence of the hepatic disease due to excessive insulin resistance or may be caused by classical type 2 diabetes.

Blood glucose determination

Patients with chronic liver disease frequently have a normal fasting glucose despite manifest type 2 diabetes with postprandial excessive increases in glucose. Therefore, oral glucose tolerance tests should be performed after diagnosis of hepatic cirrhosis.

Prognosis

Diabetes mellitus is associated with increased mortality and an increased risk of complications of liver cirrhosis including premature death, hepatocellular carcinoma, hepatic encephalopathy, and spontaneous bacterial peritonitis. Therapy of diabetes should include metformin and α?glucosidase inhibitors which can reduce the risk of these complications. Therefore, the diagnosis of diabetes has important consequences in chronic liver disease.

     

Treatment of acute hepatitis C: recommendations from an expert panel of the Italian Society of Infectious and Tropical Diseases

Aim

This paper is aimed at providing practical recommendations for the management of acute hepatitis C (AHC).

Methods

This is an expert position paper based on the literature revision. Final recommendations were graded by level of evidence and strength of the recommendations.

Results

Treatment of AHC with direct-acting antivirals (DAA) is safe and effective; it overcomes the limitations of INF-based treatments.

Conclusions

Early treatment with DAA should be offered when available.

     

Transanale offene Hämorrhoidopexie

Aim

To investigate the long-term success after transanal open hemorrhoidopexy after a follow-up period of at least 8 years

Methods

All patients were operated on at our office. Of 148 patients who underwent surgery more than 8 years ago, 110 were reached and were able to complete a questionnaire.

Results

There were no perioperative complications. The follow-up period was at least 97 months (median 123.4 months). Surgical indications were symptomatic second- or third-degree hemorrhoids. The most common symptoms were bleeding (n?=?89) and foreign body sensation (n?=?50). Immediately postoperatively, the symptoms were significantly improved or completely disappeared in 80 patients (72.7%). At the time of follow-up, 71 patients (64.5%) had no complaints and 38 patients (34.5%) had complaints. Ninety-six patients (87.3%) indicated that they would choose transanal open hemorrhoidopexy again, while 12 patients (10.9%) would not do so. In 25 patients (22.7%) another operation had been performed, in 14 of them a new hemorrhoidopexy.

Conclusion

After more than 8 years of follow-up, two-thirds of patients were symptom-free. Twenty-five patients (22.7%) underwent further surgery. Transanal open hemorrhoidopexy is a safe operation with encouraging long-term results and should be included in the treatment algorithm for symptomatic hemorrhoidal disease.

     

Prädiktoren für die Notwendigkeit antibradykarder und antitachykarder Stimulation nach ICD-Implantation

Background

Little is known about the incidence and risk factors for progression to pacemaker dependency or the need for cardiac resynchronization in typical patients with an implanted defibrillator with regard to an alternative implantation of a subcutaneous ICD (S-ICD).

Study design and methods

After retrospective analysis of 291 patients with first implantation of a transvenous single chamber ICD (VVI-ICD) from 2010–2016 and excluding those with an indication for pacemaker or lack of follow-up data, 121 patients were included and investigated with regard to the following endpoints: need for pacemaker stimulation, upgrade for cardiac resynchronization (CRT), and secondary occurrence and effectiveness of antitachycardia pacing (ATP). We compared the results with those of fundamental S?ICD studies and tried to determine risk factors on the basis of medical history and pre-implant data.

Results

The study population and the rate of endpoints were significantly different to those of fundamental S?ICD studies. Within a 2.2-year follow-up, 14.9?% of the patients developed a need for pacemaker stimulation and 0.8?% the need for cardiac resynchronization. Excluding patients who at implantation were already at high risk for pacemaker dependency, 7.4?% remained with a reached endpoint. We identified atrial fibrillation and bundle-branch-block as risk factors. All episodes of ventricular tachycardia (VT) could be terminated by ATP in 9.9?% of the patients. They more often had ischemic heart disease and a secondary prophylactic indication for an ICD.

Conclusion

The low rate of conversions from S?ICD to a transvenous ICD in case of pacemaker-dependency as stated in fundamental S?ICD studies should not be transferred to other typical collectives of ICD recipients. The latter group is at significantly higher risk for developing pacemaker-dependency.