Sacral neuromodulation in urology - development and current status

Sacral neuromodulation (SNM) in urology is employed to treat refractory lower urinary tract dysfunction as well as chronic pelvic pain. Electrical stimulation of the sacral afferents (S2?-?S4) causes activation and conditioning of higher autonomic and somatic neural structures and thereby influences the efferents controlling the urinary bladder, the rectum and their related sphincter systems. It is therefore possible to treat overactivity as well as hypocontractility and functional bladder neck obstruction. SNM treatment is conducted biphasically. Initially, test electrodes are placed to evaluate changes in micturition and pain parameters. If, in this first phase - called peripheral nerve evaluation (PNE test) - sufficient improvements are observed, the patient progresses to phase two which involves implantation of the permanent electrodes and impulse generator system. In recent years, the "two stage approach" with initial implantation of the permanent electrodes has been favoured as it increases treatment success rates. Long-term success rates of SNM vary significantly in the literature (50?-?80?%) due to heterogeneous patient populations as well as improved surgical approaches. With the introduction of "tined lead electrodes" (2002), tissue damage is reduced to a minimum. Technical innovation, financial feasibility (reimbursed in Germany since 2004) and wider application, especially in otherwise therapy-refractory patients or complex dysfunctions of the pelvis, have established SNM as a potent treatment option in urology.     

13th St. Gallen International Breast Cancer Conference 2013: Primary Therapy of Early Breast Cancer Evidence,Controversies, Consensus – Opinion of a German Team of Experts (Zurich 2013)

Zusammenfassung

Alle zwei Jahre findet in St. Gallen (Schweiz) die internationale Konsensuskonferenz zur Behandlung des primären Mammakarzinoms statt. Da sich das internationale Panel in St. Gallen aus Experten unterschiedlicher Länder zusammensetzt, spiegelt der Konsensus ein internationales Meinungsbild wider. Vor diesem Hintergrund erscheint es aus deutscher Sicht sinnvoll, die Abstimmungsergebnisse für den Therapiealltag in Deutschland zu konkretisieren. Eine deutsche Arbeitsgruppe mit acht Brustkrebsexperten, von denen zwei Mitglieder des internationalen St. Gallen-Panels sind, hat daher die Abstimmungsergebnisse der St. Gallen-Konsensuskonferenz (2013) für den Klinikalltag in Deutschland kommentiert. Inhaltliche Schwerpunkte der diesjährigen St. Gallen-Konferenz waren operative Fragestellungen der Brust und der Axilla, strahlentherapeutische und systemische Therapieoptionen sowie die klinische Relevanz der Tumorbiologie. Intensiv diskutiert wurde der klinische Einsatz von Multigen-Assays, inkl. ihrer Bedeutung für die individuelle Therapieentscheidung.     

Intraoperative radiotherapy of breast cancer

In the systemic therapy of breast cancer, the tumor itself has become the specific target. If possible the surgical excision of breast carcinoma is restricted to the tumor site and aims at an R0 resection of the invasive and preinvasive portions of the carcinoma. Only percutaneous whole-breast radiotherapy irradiates the whole breast. The additional boost irradiation is targeted and significantly improves local control in all age groups. Due to the increased detection of small breast carcinomas in postmenopausal patients by mammographic screening, it is necessary to consider a change of the existing therapeutic practice. Published results of partial irradiation of the breast (intra- as well as postoperatively) show a very high degree of local control with follow-ups of up to 11 years. At present prospective and randomized studies investigate for which patients an intraoperative radiotherapy is sufficient as the sole irradiation method after previous surgery. Intraoperative radiotherapy as a boost preceding percutaneous whole-breast irradiation should already be possible according to a relevant statement of the DEGRO.     

Nachsorge des Endometriumkarzinoms

Zusammenfassung Für das Endometriumkarzinom gelten die gleichen Ziele der Nachsorge wie für andere Malignome, z. B. Hilfe bei der Bewältigung von psychischen, körperlichen und sozialen krankheits-/behandlungsbedingten Problemen (Rehabilitation), und Fortführung/ Begleitung der onkologischen Therapie. Die meisten Patientinnen mit Endometriumkarzinom haben eine sehr gute Prognose (low risk). Bei ihnen ist die regelmäßige apparative Suche nach Lokalrezidiven und Fernmetastasen nicht sinnvoll, doch auch bei Patientinnen mit hohem Risiko (high risk) ist bisher kein Nachweis erbracht worden, dass sie durch regelmäßige bildgebende Diagnostik länger überleben. Regelmäßige gynäkologische und rektale Untersuchungen, vaginaler Ultraschall und zytologische Abstriche vom Scheidenstumpf sowie die Kolposkopie dienen der Erkennung von operablen Frührezidiven und Nebenwirkungen der Strahlentherapie, wie Scheidenstenose und Serometra. Die meisten Lokalrezidive treten innerhalb der ersten 2 Jahre auf. Um eine frühzeitige Behandlung zu ermöglichen, sollten die Nephrosonographie zur Diagnose einer asymptomatischen Nierenstauung eingesetzt und die Patientinnen über typische Symptome von Nierenstauung und Ileus (besonders nach paraaortaler Lymphonodektomie und Bestrahlung) aufgeklärt werden. Wegen der Koinzidenz des Auftretens von Endometrium- und Mammakarzinomen sollten die Patientinnen eine jährliche Mammographie erhalten.     

Inpatient medical rehabilitation in diabetes mellitus in light of evidence based practice guidelines: an evaluation on the basis of BfA routine data

OBJECTIVE: Multidisciplinary team care is an opportunity to improve the long-term metabolic situation of patients with diabetes mellitus, hence can help reduce the individual and financial burden of diabetes-related complications. The aim of this study is to evaluate the extent to which patients undergoing rehabilitation carried by the German Federal Insurance Institute for Salaried Employees (BfA) were treated in accordance with recent evidence-based clinical practice guidelines on diabetes mellitus. METHODS: We extracted specific treatment recommendations relevant to inpatient rehabilitation from national and international evidence-based guidelines and allocated them to general subjects of diabetes care (e. g. [disease specific] education, physical activity, psychosocial interventions). In the "Classification of Therapeutic Procedures (KTL)", an instrument used to classify therapeutic procedures in rehabilitation, we then identified those procedures that represented the recommendations of the guidelines. The coded procedures were allocated to the general aspects of diabetes care, too. In total, 9 "therapeutic modules" were designed, each containing guideline-recommendations and coded procedures. Using the KTL codes documented as a routine in discharge reports, we were able to describe, analyse and evaluate the procedures performed during rehabilitation. The data set we used contained KTL codes and medical information from 9,456 patients whose rehabilitation was carried by the BfA diagnosed with either diabetes mellitus type 1 or 2, who received an inpatient rehabilitation procedure during the years 2000 and 2001. RESULTS: The number of patients who received at least one procedure out of the particular therapeutic module is as follows (numbers in brackets represent the total number of KTL codes in that therapeutic module): Therapeutic module "Education (3)" - 98.66 %, "Exercise Training (63)" - 92.42 %, "Nutrition Training (14)" - 96.44 %, "Stress (18)" - 35.33 %, "Motivation (15)" - 82.87 %, "Coping Skills (15)" - 27.42 %, "Social Work (26)" - 11.44 %, "Alcohol and Nicotine (24)" - 3.69 %, "Diabetic Complications (81)" - 75.42 %. On average patients received procedures out of 5.2 different therapeutic modules. The results were consistent over subgroups (type 1/type 2 diabetes, men/women) but varied considerably between clinics. The care provided in clinics with higher numbers of diabetic patients is more in line with guideline specifications. DISCUSSION: A substantial number of patients received procedures out of the therapeutic modules "Education", "Exercise Training", "Nutrition Training" and "Motivation". In other therapeutic modules (e. g. "Alcohol and Nicotine") deficits were noted. These deficits as well as the substantial variation between clinics demonstrate the need to develop clinical practice guidelines for rehabilitation of patients with diabetes. In principle, the results of this study have to be interpreted carefully because we did not examine to which extent the documented processes are in accordance with the realities. CONCLUSIONS: Inpatient rehabilitation of diabetic patients carried by the BfA can be characterised as multidisciplinary and in accordance with the recommendations of recent evidence-based guidelines. Certain problematic aspects should be put into focus. A guideline taking into account all rehabilitative aspects, including the preparation for and the care after the rehabilitation process, can be instrumental in reducing deficits in rehabilitative care as well as differences between clinics. To gain wide acceptance, guideline development should be coordinated by a scientific institute and involve members of all groups concerned (e. g. the rehabilitative team, GPs, patients). Within certain limits the "KTL" instrument permits evaluation of process quality in rehabilitation of patients with diabetes mellitus.     

Pre-operative staging of cervical cancer: comparison of magnetic resonance imaging (MRI) and computed tomography (CT) with histologic results

Thirty-two patients with histologically confirmed cervical carcinoma were preoperatively investigated using MRI; in addition, a CAT-scan was performed on 15 of these patients. The diagnostic results using both modalities were compared with the histological findings (after hysterectomy according to Wertheim-Meigs, including lymph node dissection in the pelvic and, in part, in para-aortal regions). Determination of tumour volume was possible with high accuracy using MRI. Accuracy in assessing the parametria was 86%, vagina 90%, bladder and rectum 97%. The shortcoming of MRI is still the detection of infiltrated lymph nodes. The accuracy of 69% achieved for lymph nodes is equal to results with computed tomography. The general accuracy for our patients in staging was 81% for MRI versus 47% for CT. MRI-based diagnosis enables us to determine a correct tumour staging preoperatively, and is therefore very helpful in planning an adequate therapy. If MRI were used more widely it would contribute to simplification and shortening of the preoperative diagnostic procedure in patients with cervical carcinoma.     

Maximized reduction of primary breast tumor size using preoperative chemotherapy with doxorubicin and docetaxel.

PURPOSE: To assess the toxicity and efficacy of preoperative chemotherapy with doxorubicin and docetaxel in patients with primary operable breast cancer. PATIENTS AND METHODS: Forty-two patients with histologically confirmed primary breast cancer tumors of at least 2 cm in diameter received doxorubicin (50 mg/m(2) intravenously [IV] over 15 minutes) and docetaxel (75 mg/m(2) IV over 1 hour) every 14 (24 patients) or 21 (18 patients) days for four cycles. RESULTS: The median size of the primary tumor decreased significantly, from 4 cm (range, 2 to 10 cm) to 2 cm (range, 0 to 5 cm) on physical examination and from 3.4 cm (range, 1 to 8 cm) to 1. 8 cm (range, 0 to 4 cm) on sonography (P <.001). The overall response rate as assessed by physical examination was 93%, and complete remission of the primary tumor occurred in 33% of patients. The remission rate as assessed by sonographic measurement was 67%. Two patients (5%) had histologically confirmed complete responses. Sonography was more reliable than palpation in predicting histologically determined response. No grade 4 toxicity was noted, and grade 3 toxicity was reported with alopecia (95%), lethargy (17%), loss of appetite (10%), stomatitis (7%), leukopenia (5%), skin desquamation (5%), infection (5%), motor neuropathy (2%), and nausea (2%). The 3-week schedule was associated with less toxicity than the 2-week schedule. CONCLUSION: Preoperative combination chemotherapy with doxorubicin and docetaxel is highly effective and feasible in primary operable breast cancer.     

Natural killer T cells are dispensable in the development of allergen-induced airway hyperresponsiveness, inflammation and remodelling in a mouse model of chronic asthma

Natural killer T (NK T) cells have been shown to play an essential role in the development of allergen-induced airway hyperresponsiveness (AHR) and/or airway inflammation in mouse models of acute asthma. Recently, NK T cells have been reported to be required for the development of AHR in a virus induced chronic asthma model. We investigated whether NK T cells were required for the development of allergen-induced AHR, airway inflammation and airway remodelling in a mouse model of chronic asthma. CD1d^−/− mice that lack NK T cells were used for the experiments. In the chronic model, AHR, eosinophilic inflammation, remodelling characteristics including mucus metaplasia, subepithelial fibrosis and increased mass of the airway smooth muscle, T helper type 2 (Th2) immune response and immunoglobulin (Ig)E production were equally increased in both CD1d^−/− mice and wild-type mice. However, in the acute model, AHR, eosinophilic inflammation, Th2 immune response and IgE production were significantly decreased in the CD1d^−/− mice compared to wild-type. CD1d-dependent NK T cells may not be required for the development of allergen-induced AHR, eosinophilic airway inflammation and airway remodelling in chronic asthma model, although they play a role in the development of AHR and eosinophilic inflammation in acute asthma model.