Klaus Kraywinkel

Assessment of Functioning and Disability After Ischemic Stroke

Background and Purpose— Functioning and disability after ischemic stroke are clinically meaningful and of major relevance to patients. Despite many instruments available to assess these outcomes, little is known about their interrelation and predictive factors. Methods— We prospectively identified 4264 patients with acute ischemic stroke from 30 hospitals in Germany during a 1-year period between 1998 and 1999 and registered them in a common data bank. The patients were centrally followed up via telephone interview after 100 days and 1 year to assess various scales such as the Barthel Index (BI), modified Rankin Scale (MRS), extended Barthel Index (EBI), Short Form-36 Physical Functioning (SF-36 PF), and Center for Epidemiologic Studies–Depression short form (CES-D). Results— Outcome status could be assessed in 67.2% of patients 100 days after hospital admission. Of these, 13.9% had died, 53.7% had regained functional independence (BI <95), 46.3% had no or mild residual symptoms (MRS ≤1), and 44.6% had no higher cognitive deficits on the EBI. Of the patients who personally answered the follow-up questions, 67% had no major physical disability (SF-36 PF <60), and 32.9% reported symptoms classified as depression (CES-D ≥10). The high percentage of patients reaching the maximum score (ceiling effect) in the BI was less pronounced in the MRS and SF-36 PF. The predictive factors for dichotomized outcomes on each scale were similar for adverse functioning and disability but varied considerably for depression. Conclusions— To avoid ceiling effects in outcome distribution of patients treated in specialized stroke centers, the MRS and SF-36 PF instruments are preferable to the BI. Parametric use of the SF-36 PF could further improve outcome measurement by considering individual treatment effects.

Development and Implementation of Evidence-Based Indicators for Measuring Quality of Acute Stroke Care The Quality Indicator Board of the German Stroke Registers Study Group (ADSR)

Background and Purpose— There is no consensus about indicators for measuring quality of acute stroke care in Germany. Therefore, a standardized process was initiated recently to develop and implement evidence-based indicators for the measurement of quality of acute hospital stroke care. Methods— Quality indicators were developed by a multidisciplinary board between November 2003 and December 2005. The process was initiated by the German Stroke Registers Study Group in cooperation with the German Stroke Society, the German Society of Neurology, the German Stroke Foundation, Regional Offices for Quality Assurance and other experts proven in the field. National and international recommendations were considered during the development process. The process was based on a systematic literature review, an independent external evaluation of the process and its results, and a prospective pilot study to evaluate the defined indicators in clinical practice. Results— Overall a set of 24 indicators was developed to measure performance of acute care hospitals in the 3 health care dimensions structure, process and outcome as well as in 3 treatment phases prehospital, in-hospital/acute and postacute. Practicability of the derived indicators was tested in a prospective pilot study. During a 2-month period, 1006 patients in 13 hospitals were documented. Application of the new indicator set was found to be feasible by participating physicians and hospitals. Median time to document the required information for 1 patient was 5 minutes. Nationwide implementation of the new indicator set within regional registers in Germany started since April 2006. Conclusions— The development of indicators to measure hospital performance in stroke care is an important step toward improving stroke care on a national level. The chosen standardized evidence-based approach ensures maximal transparency, acceptance and sustainability of the developed indicators in Germany.

Krebs in Deutschland 2005/2006 - Häufigkeiten und Trends

Die Broschüre »Krebs in Deutschland« wird alle zwei Jahre als gemeinsame Publikation der Gesellschaft der epidemiologischen Krebsregister e. V. (GEKID) und des Robert KochInstituts (RKI) herausgegeben. Die vorliegende 6. Auflage erscheint mit neuem Design erstmalig in der Reihe der Berichte der Gesundheitsberichterstattung (GBE) des Bundes. Sie enthält Angaben zu den in Deutschland im Zeitraum von 1980 bis zum Jahr 2004 insgesamt aufgetretenen Krebsneuerkrankungen und zu ausgewählten Einzellokalisationen, die jeweils kurz und übersichtlich dargestellt werden (Erkrankungsund Sterberaten, Risikofaktoren, Trendverläufe, Überlebensaussichten). Die aktuellen Schätzungen des RKI basieren auf den Daten vollzählig erfassender epidemiologischer Krebsregister in Deutschland. Für das Jahr 2004 weist diese Schätzung insgesamt 436.500 Krebsneuerkrankungen aus (Männer 230.500, Frauen 206.000). Damit sind im Vergleich zur vorangegangenen Schätzung, die mit dem Jahr 2002 abschloss, im Jahr 2004 etwa 12.000 Krebsneuerkrankungen mehr aufgetreten. Bei Frauen blieb die Gesamtzahl dieser Erkrankungen gegenüber 2002 unverändert. Die zusätzlichen Erkrankungsfälle im Jahr 2004 sind überwiegend auf Erkrankungen der Männer an Prostatakrebs zurückzuführen, der mit etwa 58.500 Erkrankungsfällen die häufigste Krebserkrankung bei Männer darstellt. Bei den Frauen steht, wie in den vorangegangenen Schätzungen auch, der Brustkrebs mit etwa 57.000 Neuerkrankungen an erster Stelle. Im Jahr 2004 verstarben insgesamt 208.800 Personen in Deutschland an Krebs, im Jahr 2002 waren es noch 209.900. Die Überlebensaussichten mit Prostatakrebs und Brustkrebs haben sich so weit verbessert, dass die Zahl der Krebssterbefälle daran mittlerweile abnimmt. Im Jahr 2004 verstarben 11.200 Männer an Prostatakrebs und 17.600 Frauen an Brustkrebs. Das sind jeweils 200 Sterbefälle weniger als noch zwei Jahre zuvor. Angaben zu Krebs erkrankungen bei Kindern werden vom Kinderkrebsregister Mainz in einem eigenen Abschnitt der Broschüre dargestellt.

Length of Barrett's oesophagus and cancer risk: implications from a large sample of patients with early oesophageal adenocarcinoma

Objective Although it is well understood that the risk of oesophageal adenocarcinoma increases with Barrett length, transition risks for cancer associated with different Barrett lengths are unknown. We aimed to estimate annual cancer transition rates for patients with long-segment (≥3 cm), short-segment (≥1 to <3 cm) and ultra-short-segment (<1 cm) Barretts oesophagus. Design We used three data sources to estimate the annual cancer transition rates for each Barrett length category: (1) the distribution of long, short and ultra-short Barretts oesophagus among a large German cohort with newly diagnosed T1 oesophageal adenocarcinoma; (2) population-based German incidence of oesophageal adenocarcinoma; and (3) published estimates of the population prevalence of Barretts oesophagus for each Barrett length category. Results Among 1017 patients with newly diagnosed T1 oesophageal adenocarcinoma, 573 (56%) had long-segment, 240 (24%) short-segment and 204 (20%) ultra-short-segment Barretts oesophagus. The base-case estimates for the prevalence of Barretts oesophagus among the general population were 1.5%, 5% and 14%, respectively. The annual cancer transition rates for patients with long, short and ultra-short Barretts oesophagus were 0.22%, 0.03% and 0.01%, respectively. To detect one cancer, 450 patients with long-segment Barretts oesophagus would need to undergo annual surveillance endoscopy; in short segment and ultra-short segment, the corresponding numbers of patients would be 3440 and 12 364. Similar results were obtained when applying US incidence data. Conclusions The large number of patients, who need to undergo endoscopic surveillance to detect one cancer, raises questions about the value of surveillance endoscopy in patients with short segment or ultra-short segment of Barretts oesophagus.

Krebs in Deutschland 2003-2004 Häufigkeiten und Trends

Die Broschüre »Krebs in Deutschland« wird alle zwei Jahre als gemeinsame Publikation der Gesellschaft der epidemiologischen Krebsregister e. V. (GEKID) und des Robert KochInstituts (RKI) herausgegeben. Die vorliegende 6. Auflage erscheint mit neuem Design erstmalig in der Reihe der Berichte der Gesundheitsberichterstattung (GBE) des Bundes. Sie enthält Angaben zu den in Deutschland im Zeitraum von 1980 bis zum Jahr 2004 insgesamt aufgetretenen Krebsneuerkrankungen und zu ausgewählten Einzellokalisationen, die jeweils kurz und übersichtlich dargestellt werden (Erkrankungsund Sterberaten, Risikofaktoren, Trendverläufe, Überlebensaussichten). Die aktuellen Schätzungen des RKI basieren auf den Daten vollzählig erfassender epidemiologischer Krebsregister in Deutschland. Für das Jahr 2004 weist diese Schätzung insgesamt 436.500 Krebsneuerkrankungen aus (Männer 230.500, Frauen 206.000). Damit sind im Vergleich zur vorangegangenen Schätzung, die mit dem Jahr 2002 abschloss, im Jahr 2004 etwa 12.000 Krebsneuerkrankungen mehr aufgetreten. Bei Frauen blieb die Gesamtzahl dieser Erkrankungen gegenüber 2002 unverändert. Die zusätzlichen Erkrankungsfälle im Jahr 2004 sind überwiegend auf Erkrankungen der Männer an Prostatakrebs zurückzuführen, der mit etwa 58.500 Erkrankungsfällen die häufigste Krebserkrankung bei Männer darstellt. Bei den Frauen steht, wie in den vorangegangenen Schätzungen auch, der Brustkrebs mit etwa 57.000 Neuerkrankungen an erster Stelle. Im Jahr 2004 verstarben insgesamt 208.800 Personen in Deutschland an Krebs, im Jahr 2002 waren es noch 209.900. Die Überlebensaussichten mit Prostatakrebs und Brustkrebs haben sich so weit verbessert, dass die Zahl der Krebssterbefälle daran mittlerweile abnimmt. Im Jahr 2004 verstarben 11.200 Männer an Prostatakrebs und 17.600 Frauen an Brustkrebs. Das sind jeweils 200 Sterbefälle weniger als noch zwei Jahre zuvor. Angaben zu Krebs erkrankungen bei Kindern werden vom Kinderkrebsregister Mainz in einem eigenen Abschnitt der Broschüre dargestellt.

Recurrent stroke after cervical artery dissection

Objective Cervical artery dissection (CAD) accounts for 10–20% of all strokes in young adults, but no randomised controlled trial has investigated the best secondary prevention after ischaemic stroke or transient ischaemic attack (TIA). Because only small numbers of patient with CAD have been prospectively documented and followed up, the authors aimed to investigate the prognosis under various prevention regimens. Methods 30 German departments of neurology with acute stroke units prospectively documented 250 patients with acute ischaemic stroke or TIA due to CAD. A central follow-up (median 31 months) assessed recurrent stroke, recurrent CAD and death in 198 patients. Results CAD was found more often in the carotid arteries (52.0%) than in the vertebral arteries (46.8%). Thirteen patients (5.2%, CI 3.1% to 8.6%) suffered a recurrent stroke during the acute hospital stay. The rate of recurrent CAD during the first year was 1.7% (95% CI 0.3% to 3.6%). The cumulative recurrent stroke rate during the first year was 10.7% (95% CI 6.5% to 14.9%) and 14.0% (95% CI 8.9% to 19.1%) over 3 years. After discharge, the rate of recurrent stroke up to 6 months in patients treated with anticoagulants was 2.0% (95% CI 0.6% to 7.1%) and in those treated with antiplatelets 16.7% (95% CI 5.8% to 39.2%), which was statistically significant (HR 0.11; CI 0.02 to 0.69, p=0.02). Conclusions This observational study confirms a high risk of early recurrent stroke following acute IS or TIA due to CAD. Whether anticoagulation provides any benefit over antiplatelets needs to be investigated in a randomised controlled trial.

Changes in cancer incidence attributable to tobacco smoking in Germany, 1999-2008.

Tobacco smoking, a major cancer risk factor, is very common in Germany as in many other high‐income countries. Few studies have assessed the burden of tobacco‐associated cancer incidence in the German population. We calculated the proportion of cancers attributable to tobacco smoking to estimate the burden of tobacco‐associated cancer in 1999 and 2008. Smoking prevalence was determined from national surveys of a representative sample of the German population in 1998 and 2008–2011, and data on relative risks were obtained from meta‐analyses. Cancer incidence for the years 1999 and 2008 was estimated by the German Centre for Cancer Registry Data at the Robert Koch Institute. We estimate that 72,208 incident cancer cases were attributable to tobacco smoking in Germany in 2008, an increase of >6,200 cases over 1999 levels. Among the cases in 2008 were 55,057 cases among men (22.8% (95% CI, 21.3–24.1) of all new cases) and 17,151 cases among women (7.9% (95% CI, 7.21–8.68) of all new cases). The highest proportions attributable to smoking were estimated for cancer of the lung, larynx, pharynx and the lower urinary tract. Tobacco smoking is currently responsible for more than one in five cancer cases among men and nearly 1 in 12 among women. Considering the increasing trends in cancer incidence and, until very recently, rising prevalence of smoking among women, it can be expected that the number of tobacco‐attributable cancer cases will rise further.

Incidence Patterns and Temporal Trends of Invasive Nonmelanotic Vulvar Tumors in Germany 1999-2011. A Population-Based Cancer Registry Analysis

Objectives Time trends on the incidence and characteristics of invasive vulvar cancer in Germany have so far been studied in few local population- and hospital based tumor registries. We aimed to provide an overview on recent developments of vulvar cancer in Germany, using population-based cancer registry data. Methods We analyzed the data on vulvar cancer of eight population-based German cancer registries for the period 1999-2011. ICD-10 codes and ICD-O-3 morphology codes were used to select site and histologic types. The annual percentage change was calculated on age-adjusted incidence rates with a joinpoint regression model. Results A total of 12,711 registered cases of invasive carcinoma of the vulva were included in the analyses, hereof were 12,205 of squamous cell origin. Age-standardized incidence rates of vulvar cancer annually increased by 6.7% (95% confidence limits: 5.6-7.9) from 1.7 per 100,000 women in 1999 to 3.6 per 100,000 women in 2011. An increase was observed among women of all ages, and especially between 30 and 69 years of age. Conclusion The annual incidence of invasive carcinoma of the vulva nearly doubled in the past decade in Germany, considerably exceeding the rates observed in other Western European countries. A combination of changes in risk factors, and documentation practice might have contributed to the observed substantial increase in vulvar cancer incidence.

Überlebenschancen von krebspatienten in Deutschland - Auf dem weg zu repräsentativen, vergleichbaren aussagen

Cancer is an important issue within the German health care system with an estimated annual number of 435 000 incident cases and almost 210 000 deaths. Data of population-based cancer registries enable us to identify improvements of survival in oncological patients due to progress in therapeutic care and secondary prevention, as well as to investigate regional and international differences of this outcome. Comparing cancer survival rates, however, requires considering the impact of both methodical approaches and data quality. Potential factors of influence like algorithms, reference population, completeness of case ascertainment and quality of follow-up are discussed. For the first time harmonized proceedings are recommended in order to achieve comparability of population-based cancer survival rates in Germany.

Von regionalen Daten zu bundesweiten Aussagen

Despite having achieved nationwide registry coverage in addition to substantial improvements in data on the epidemiology of cancer in Germany, the Centre for Cancer Registry Data continues to estimate national statistics on incidence, survival, and prevalence instead of calculating these directly from available data. The methods used for evaluations are based initially on estimates of registration completeness or, for survival analyses, an assessment of the quality of follow-up data. The completeness of incident case registration is estimated on the basis of the mortality/incidence procedure, which assumes a largely constant relationship between the mortality and incidence of a cancer type among people of the same age and sex across federal states. Inclusion criteria for consideration of registry data in national survival analyses are less than 15% of death certificate only (DCO) cases and plausible survival for patients with pancreatic cancer or metastatic lung cancer. Of the 477,300 incident cancer cases estimated for 2010, 429,900 were reported by the cancer registries (90%), and ten federal states contributed data to national survival estimates.