Poliklinik für Endokrinologie, Diabetologie und Präventivmedizin

BACKGROUND: Breakthrough pain is transitory exacerbation of pain that occurs in addition to otherwise stable persistent pain. The wide differences in estimation of incidence reported in literature are probably because of different settings and meanings attributed to the definition of breakthrough pain. METHODS: A panel of experts met to establish the actual knowledge on breakthrough pain, according to the evidence in literature and experience. They agreed that episodic or transient pain could be a more simple and adequate term in most languages, including English, French, Italian, and Spanish. RESULTS: A specific assessment and precise pain characterization are essential to plan the most appropriate treatments. Despite the relevance of this temporal pain pattern for the influence on the outcome and quality of life, few controlled studies have been performed to give evidence of a specific approach. Several experiences have reported the possible efficacy of different drugs, route of administration, and modalities of administration in different circumstances. CONCLUSIONS: Prospective studies with previous treatments using similar terminologies are necessary to find the most convenient therapeutic intervention, according to the temporal pattern characteristics and the pain mechanism involved.

PURPOSE: This is an official interdisciplinary guideline, published and coordinated by the German Society of Gynaecology and Obstetrics (DGGG), the Austrian Society of Gynaecology and Obstetrics (OEGGG) and the Swiss Society of Gynaecology and Obstetrics (SGGG). The guideline was developed for use in German-speaking countries and is backed by the German Society of Anaesthesiology and Intensive Medicine (DGAI), the Society of Thrombosis and Haemostasis Research (GTH) and the German Association of Midwives. The aim is to provide a consensus-based overview of the diagnosis and management of peripartum bleeding obtained from an evaluation of the relevant literature. METHODS: This S2k guideline was developed from the structured consensus of representative members of the various professional associations and professions commissioned by the Guideline Commission of the DGGG. RECOMMENDATIONS: The guideline encompasses recommendations on definitions, risk stratification, prevention and management.

INTRODUCTION: Repeated assessment of pain and other symptoms is required for quality assurance in palliative care. However, physical and cognitive impairment of the patients may impede the use of standardized questionnaires and documentation systems in palliative care setting. We developed a minimal documentation system (MIDOS) for the specific requirements in this setting. METHODS: The German versions of the Brief Pain Inventory (BPI) and the quality of life questionnaire SF-12 were completed for all patients admitted to the palliative care unit. Cognitive impairment was assessed with the Mini Mental State Examination (MMSE). With admission as well as on subsequent consultations patients self-assessed average and maximum pain intensity on numeric rating scales and the intensity of drowsiness, nausea, constipation, dyspnea, weakness, anxiety and well-being on verbal categorical scales. RESULTS: From August 1998 to June 1999 128 patients were documented consecutively. Fifty-nine percent of these patients were treated with WHO-step 3 opioids. Cognitive impairment (MMSE<24) was present in 37% of the patients. Self-assessment with MIDOS was possible for 114 patients at the time of admission, and for 108 patients at the end of therapy. Pain, drowsiness and weakness were documented by most patients, whereas the other symptoms were reported less frequently. DISCUSSION: Factor analysis showed one factor for pain and two factors for the other symptoms. The pain sum score of MIDOS correlated with the factors of the BPI, the symptom sum score of MIDOS correlated with the factors of the BPI and the mental sum score of the SF-12, though on a lower level. MIDOS sum scores showed good pain relief and symptom control for patients discharged home or to other services, whereas the symptom sum score gave an indication of the deterioration in the terminal phase for those patients who died during in-patient treatment. Test-retest stability was good for a subgroup of patients with stable opioid doses. CONCLUSIONS: We conclude that MIDOS is a valid instrument for self-assessment of the patient's symptoms and may be used to monitor the efficacy of symptom management.

BACKGROUND: In 2007, the International Agency for Research on Cancer (IARC) classified shift work with circadian disruption or chronodisruption as a probable human carcinogen. Short-term disturbances of biological 24-hour-rhythms following exposures to light and darkness at unusual times are well-known as "jet-lag" and "shift-lag" symptoms. However, that chronic disturbances or disruptions of timely sequenced circadian rhythms (chronodisruption) should contribute to long-term developments of cancer is a relatively new concept. This review provides background and practical information with regard to the open question "does shift-work cause cancer?" METHODS: Overview on the basis of a selective literature search via Medline and ISI Web of Knowledge until 2009 from the viewpoints of occupational medicine, epidemiology, chronobiology, and occupational science. RESULTS: The postulated causal links between shift-work and cancer in humans are biologically plausible in the light of experimental findings, but to date we lack epidemiological studies which could describe or exonerate risks in humans. Monetary compensation has already been paid for such cases in at least one country (Denmark). In Germany, however, according to the applicable law, a new occupational disease can only be recognized when certain conditions for the recognition of "general scientific merit" have been met. We present the current state of knowledge regarding prevention. CONCLUSION: While causal links between shift-work and cancer developments are not established, future shift-work planning should pay more attention to insights from occupational medicine, chronobiology, and occupational science.

Acute lung injury is characterized by hypoxemia due to pulmonary ventilation/perfusion-mismatching. IV administered prostaglandin E1 (PGE1), a vasodilator with a high pulmonary clearance, has been studied in acute lung injury. Inhalation of the vasodilators nitric oxide and prostacyclin improved oxygenation by selective dilation of the pulmonary vasculature in ventilated lung areas. In the present study, PGE1 inhalation was used for treatment of acute lung injury. Fifteen patients with acute lung injury defined as PaO2/fraction of inspired oxygen (FIO2) <160 mm Hg were treated with PGE1 inhalation in addition to standard intensive care. The drug was continuously delivered via a pneumatic nebulizer. Acute physiology and chronic health evaluation system II and multiple organ failure scores were (mean +/- SEM) 33 +/- 2 and 10 +/- 0.3, respectively. Inhaled PGE1 was administered for 103 +/- 17 h at a dose of 41 +/- 2 [micro sign]g/h. The PaO2/FIO2 ratio increased from 105 +/- 9 to 160 +/- 17 mm Hg (P < 0.05) and to 189 +/- 25 mm Hg (P < 0.05) after 4 h and 24 h, respectively. PGE1 inhalation decreases in mean pulmonary artery pressure and central venous pressure were not statistically significant. Mean arterial pressure, pulmonary capillary wedge pressure, cardiac output, and heart rate remained unchanged. Intensive care unit mortality was 40%. The present data suggest that inhaled PGE (1) is an effective therapeutic option for improving oxygenation in patients with acute lung injury. Whether inhaled PGE1 will increase survival in acute lung injury should be investigated in a controlled prospective trial. Implications: In patients with severe acute lung injury and multiple organ failure, inhaled prostaglandin E1 improved oxygenation and decreased venous admixture without affecting systemic hemodynamic variables. Controlled clinical trials are warranted. (Anesth Analg 1998;86:753-8)

UNLABELLED: Growth factors such as nerve growth factor and glial cell line-derived neurotrophic factor are known to induce pain sensitization. However, a plethora of other growth factors is released during inflammation and tissue regeneration, and many of them are essential for wound healing. Which wound-healing factors also alter the sensitivity of nociceptive neurons is not well known. We studied the wound-healing factor, basic fibroblast growth factor (bFGF), for its role in pain sensitization. Reverse transcription polymerase chain reaction showed that the receptor of bFGF, FGFR1, is expressed in lumbar rat dorsal root ganglia (DRG). We demonstrated presence of FGFR1 protein in DRG neurons by a recently introduced quantitative automated immunofluorescent microscopic technique. FGFR1 was expressed in all lumbar DRG neurons as quantified by mixture modeling. Corroborating the mRNA and protein expression data, bFGF induced Erk1/2 phosphorylation in nociceptive neurons, which could be blocked by inhibition of FGF receptors. Furthermore, bFGF activated Erk1/2 in a dose- and time-dependent manner. Using single-cell electrophysiological recordings, we found that bFGF treatment of DRG neurons increased the current-density of NaV1.8 channels. Erk1/2 inhibitors abrogated this increase. Importantly, intradermal injection of bFGF in rats induced Erk1/2-dependent mechanical hyperalgesia. PERSPECTIVE: Analyzing intracellular signaling dynamics in nociceptive neurons has proven to be a powerful approach to identify novel modulators of pain. In addition to describing a new sensitizing factor, our findings indicate the potential to investigate wound-healing factors for their role in nociception.

Bladderworts (Utricularia, Lentibulariaceae, Lamiales) constitute the largest genus of carnivorous plants but only aquatic species (about one fifth of the genus) have so far been thoroughly studied as to their suction trap functioning. In this study, we comparatively investigated trap biomechanics in 19 Utricularia species to examine correlations between life-forms, trapping mechanisms, and functional-morphological traits. Our investigations show the existence of two functional trap principles (passive trap in U. multifida vs. active suction traps), and - in active suction traps - three main trapdoor movement types (with several subtypes). The trapdoor movement types and their corresponding functional-morphological features most presumably represent adaptations to the respective habitat. We furthermore give insights into fluid dynamics during suction in three representatives of the main types of trapdoor movement. The results on functional morphology and trapdoor movement were mapped onto a new phylogenetic reconstruction of the genus, derived from the rapidly evolving chloroplast regions trnK, rps16 and trnQ-rps16 and a sampling of 105 Utricularia species in total. We discuss potential scenarios of trap character evolution and species radiation, highlighting possible key innovations that enable such a unique carnivorous lifestyle in different habitats.

Future space exploration missions will take humans far beyond low Earth orbit and require complete crew autonomy. The ability to provide anaesthesia will be important given the expected risk of severe medical events requiring surgery. Knowledge and experience of such procedures during space missions is currently extremely limited. Austere and isolated environments (such as polar bases or submarines) have been used extensively as test beds for spaceflight to probe hazards, train crews, develop clinical protocols and countermeasures for prospective space missions. We have conducted a literature review on anaesthesia in austere environments relevant to distant space missions. In each setting, we assessed how the problems related to the provision of anaesthesia (e.g., medical kit and skills) are dealt with or prepared for. We analysed how these factors could be applied to the unique environment of a space exploration mission. The delivery of anaesthesia will be complicated by many factors including space-induced physiological changes and limitations in skills and equipment. The basic principles of a safe anaesthesia in an austere environment (appropriate training, presence of minimal safety and monitoring equipment, etc.) can be extended to the context of a space exploration mission. Skills redundancy is an important safety factor, and basic competency in anaesthesia should be part of the skillset of several crewmembers. The literature suggests that safe and effective anaesthesia could be achieved by a physician during future space exploration missions. In a life-or-limb situation, non-physicians may be able to conduct anaesthetic procedures, including simplified general anaesthesia.

INTRODUCTION: A study of patients with low back pain (LBP) had revealed altered central pain processing. At an equal pain level LBP patients had considerably more neuronal activation in the somatosensory cortices than controls. In a new analysis of this dataset, we further investigated the differences in central pain processing between LBP patients and controls, looking for possible pathogenic mechanisms. METHODS: Central pain processing was studied by functional magnetic resonance imaging (fMRI), using equally painful pressure stimuli in a block paradigm. In this study, we reanalyzed the fMRI data to statistically compare pain-elicited neuronal activation of both groups. RESULTS: Equally painful pressure stimulation resulted in a significantly lower increase of regional cerebral blood flow (rCBF) in the periaqueductal gray (PAG) of the LBP patients. The analysis further revealed a significantly higher increase of rCBF in LBP than in HC in the primary and secondary somatosensory cortex and the lateral orbitofrontal cortex (LOFK), elicited by these same stimuli. CONCLUSIONS: These findings support a dysfunction of the inhibitory systems controlled by the PAG as a possible pathogenic mechanism in chronic low back pain.

INTRODUCTION: Perioperative mortality of patients undergoing implantation of automatic implantable cardioverter defibrillators (ICDs) has been reduced dramatically following the availability of transvenous-subcutaneous defibrillation leads. However, patients with severely reduced left ventricular function show a substantial rate of nonsudden cardiac mortality within the first year. Whether repeated intraoperative inductions of ventricular tachycardia/fibrillation (VT/VF) during implantation lead to hemodynamic deterioration and thus might contribute to development of end-stage heart failure in these patients is unknown. The purpose of the present study was to determine cardiac output and hemodynamic performance during transvenous-subcutaneous ICD implantation in patients with severe left ventricular dysfunction. METHODS AND RESULTS: In 11 patients with a left ventricular ejection fraction (EF) < or = 0.35, cardiac output was measured automatically with a combined continuous cardiac output/mixed venous oxygen saturation pulmonary artery catheter system. ICD implantation was performed during standardized general anesthesia. In the 11 patients (EF = 27 +/- 2% [mean +/- SEM]) a total of 95 episodes of VT/VF followed by defibrillation were induced (episodes per patient = 9 +/- 1; range 6 to 11). Cardiac index was 2.2 +/- 0.2 L.min-1.m-2 after induction of anesthesia (before start of surgery), and 1.9 +/- 0.1 L.min-1.m-2 immediately before first induction of VT/VF. After the last episode of VT/VF, cardiac index was 2.1 +/- 0.2 L.min-1.m-2. Cardiac index measured 1, 2, and 3 minutes after induction of VT/VF was not significantly different when compared to the preinduction value during any episode of VT/VF induction. Similarly, stroke volume index was 39 +/- 5 mL.m-2 immediately before first induction of VT/VF and 36 +/- 3 mL.m-2 after the last episode of VT/VF (NS). At the end of surgery, hemodynamic parameters did not exhibit any significant difference when compared to the data obtained before start of ICD implantation and testing. CONCLUSION: Extensive defibrillation tests during transvenous-subcutaneous ICD implantation in patients with severe left ventricular dysfunction are not associated with acute deterioration of cardiac performance.

Many extracellular factors sensitize nociceptors. Often they act simultaneously and/or sequentially on nociceptive neurons. We investigated if stimulation of the protein kinase C epsilon (PKCε) signaling pathway influences the signaling of a subsequent sensitizing stimulus. Central in activation of PKCs is their transient translocation to cellular membranes. We found in cultured nociceptive neurons that only a first stimulation of the PKCε signaling pathway resulted in PKCε translocation. We identified a novel inhibitory cascade to branch off upstream of PKCε, but downstream of Epac via IP3-induced calcium release. This signaling branch actively inhibited subsequent translocation and even attenuated ongoing translocation. A second 'sensitizing' stimulus was rerouted from the sensitizing to the inhibitory branch of the signaling cascade. Central for the rerouting was cytoplasmic calcium increase and CaMKII activation. Accordingly, in behavioral experiments, activation of calcium stores switched sensitizing substances into desensitizing substances in a CaMKII-dependent manner. This mechanism was also observed by in vivo C-fiber electrophysiology corroborating the peripheral location of the switch. Thus, we conclude that the net effect of signaling in nociceptors is defined by the context of the individual cell's signaling history.

Normal functioning of the thyroid gland during surgery is important, but few data are available on the possible interactions between anesthesia and thyroid hormones. In two independent studies we examined the influence of different types of general anesthesia on the plasma levels of the thyroid hormones. They revealed an intraoperative increase of free thyroxine (fT4) and total thyroxine (tT4) in plasma to approximately 150% of preanesthesia levels when enflurane was used. No increase in thyroid-stimulating hormone (TSH) secretion was noted prior to this. The increase was not due to a quantitative change in the binding proteins. The plasma levels of fT4 and tT4 returned to normal postoperatively; however, no accompanying increase in plasma triiodothyronine levels was observed. Hence we assume the increase to be due to hormone release from thyroid and/or extrathyroidal stores--an intercompartmental shifting.

Schwere peri-(post-)partale Blutungen (PPH) sind auch heute noch weltweit eine der häufigsten Ursachen der mütterlichen Mortalität und Morbidität. Sie sind eine interdisziplinäre Herausforderung und machen eine enge Kooperation insbesondere zwischen Geburtshelfern und Anästhesisten notwendig. Die Kenntnis aktueller Leitlinien und Empfehlungen, die Verfügbarkeit lokaler Handlungspläne, die regelmäßige Schulung des Personals sowie die adäquate Beurteilung des klinischen Zustands der Patientin mit sorgfältiger Einschätzung oder Messung des Blutverlusts sowie die zeitgerechte Erkennung eines drohenden hypovolämischen Schockes sind dabei wichtige Voraussetzungen. Bei schwerer PPH mit persistierender Blutung sind die Aufrechterhaltung der Normothermie und normaler Kalziumkonzentrationen sowie die Korrektur einer metabolischen Azidose durch den Anästhesisten wichtige Voraussetzungen für die Gabe von Gerinnungsfaktoren. Eckpfeiler der Behandlung ist die Wiederherstellung des Blutvolumens und die Erhaltung einer ausreichenden Oxygenierungskapazität durch die Substitution von Sauerstoffträgern. Zur Vermeidung eines hypovolämischen Schockes ist eine ausreichende Flüssigkeitstherapie mit kristalloiden und kolloidalen Lösungen (z. B. HES 130/0,4) unerlässlich, bei Hämoglobinspiegeln ≤ 6–8 g/dl die Transfusion von Erythrozyten. Bei klinischen Hinweisen auf eine Gerinnungsstörung (Hyperfibrinolyse) wird die intravenöse Gabe von 2 g Tranexamsäure empfohlen, noch bevor die Ergebnisse der Gerinnungsteste vorliegen. Tranexamsäure sollte immer vor der Gabe von Fibrinogen appliziert werden. Bei akuter und anhaltender Blutung sowie einem Blutverlust von 2000–3000 ml ist der unverzügliche Ersatz von Gerinnungsfaktoren durch die Gabe von gefrorenem Frischplasma (GFP, 20–30 ml/kgKG) und Fibrinogen (3–4 g) erforderlich. Fibrinogenkonzentrationen von > 1,5–2,0 g/l sollten aufrechterhalten werden. Entsprechend den vor Kurzem publizierten Leitlinien der BÄK (Bundesärztekammer) sollte bei schweren anhaltenden Blutungen durch die Gabe von Thrombozytenkonzentraten die Thrombozytenzahl auf > 100 000/µl gehalten werden. Die Anwendung von rekombinantem Faktor VIIa (rFVIIa, Dosis: 90 µg/kgKG) ist nur nach Ausschöpfung aller chirurgischen und die Hämostase stabilisierenden Maßnahmen (s. o.) zu erwägen, wenn möglich vor Durchführung einer Hysterektomie, um diese zu vermeiden. Vor der Gabe von rFVIIa müssen die hämostaseologischen Voraussetzungen für dessen Anwendung geschaffen werden. Antithrombin oder Heparin sollten bei Patientinnen mit PPH nicht gegeben werden, solange eine erhöhte Blutungsgefahr besteht. Die Anwendung eines Cell Savers ist eine geeignete Methode, um die Zahl der Bluttransfusionen zu reduzieren.

Binding of 125I-LH-RH and its analogue, 125I-6-D-Leu-10-Des-Gly-Ethylamide-LH-RH (6-D-LH-RH) in male serum was studied in 10 healthy males and in 11 patients with idiopathic gonadotropin deficiency (IGD) before and during treatment with 6-D-LH-RH. Using either equilibrium dialysis (A) or ethanol precipitation (B) 13.57 +/- 0.69% (A) or 19.32 +/- 1.73% (B) of LH-RH and 7.12 +/- 0.86% (A) or 14.56 +/- 1.06% (B) of the analogue were in the bound form, without difference between normal subjects and IGD. Capacity of this binding was high (greater than 9 less than 18 mu-Mol LH-RH/0.06 mMol of protein), affinity very low, and the binding almost completely disappeared following removal of albumins by affinity chromatography. Chronic treatment with 6-D-LH-RH did not alter these binding characteristics. These observations suggest non specific albumin binding of LH-RH in male serum and stress the role of this decapeptide as a rapid modulating regulator of gonadotropin secreting system.

UNLABELLED: BACKGROUND AND GOAL OF STUDY: Older patients are said to be more sensitive to analgesics and to have a higher risk of side effects due to pharmacokinetic changes developing with old age. On account of this many elderly patients with cancer pain are denied adequate analgesic treatment. We compared efficacy and side effects of cancer pain management in different age groups. METHODS: From 1994 to April 1996 577 cancer patients were treated in our pain clinic according to WHO-Guidelines. Efficacy and side effects were evaluated for 508 patients (< 65 years = G1: 323 patients, 65-74 years = G2: 127 patients, > 74 years = G3: 58 patients) with a computerised documentation system. RESULTS: 508 patients were treated on 42,123 days and revisited on 5572 controls. 30 patients were treated longer than 1 year (G1 21 patients, G2 6 patients, G3 3 patients). 143 patients were treated until death. 286 patients were treated on 19,448 days with oral morphine. (G1: 1712 days; G2: 3645 days; G3: 2364 days). Geriatric patients (G3) received significantly higher doses of morphine than younger patients. Adjuvant drugs were given on 81% of treatment days (G1 84%, G2 75%, G3 75%). Incidence and intensity of side effects were not increased in older patients with the exception of urinary disorders. CONCLUSIONS: Geriatric patients with cancer pain can be treated as effectively according to WHO-Guidelines as younger patients. In our study patients in the old age group received significantly higher doses of oral morphine. When analgesic drugs are titrated according to individual needs, side effects are not more frequent or severe than in younger patients.

Wir untersuchten die Gültigkeit von einfachen Summenformeln zur Gefährdungsbeurteilung bei Exposition gegenüber mehreren (krebserzeugenden) Arbeitsstoffen unter der Annahme binärer Expositionen und eines deterministischen Respons. Das Umweltbundesamt organisierte ein externes Review unserer Arbeit. Die Gutachter unterstützen unsere Hauptaussage, dass Summenformeln keine allgemeine Gültigkeit haben können, haben aber ergänzende Fragen gestellt. In diesem Nachtrag möchten wir die wissenschaftliche Öffentlichkeit darüber informieren und auf die gestellten Fragen eingehen. Wir zeigen, dass die wesentlichen Aussagen im oben genannten Beitrag gültig bleiben, auch wenn die Expositionen intervallskaliert sind oder der binäre Respons probabilistisch ist oder die Analysen auf Responstypen eingeschränkt werden, die adverse Effekte beschreiben. Wir stellen zudem klar, dass Exzessrisiken und Differenzen von Exzessrisiken keine Wahrscheinlichkeiten im Sinne der Kolmogorov-Axiome darstellen. Einfache Summenformeln haben damit keine Rechtfertigung, auch nicht zur Abschätzung des Exzessrisikos von unten.

The new nondepolarizing muscle relaxant rocuronium belongs to the chemical group of aminosteroidal muscle relaxants and is similar to vecuronium in its chemical structure and pharmacologic action. The principal clinical advantage of rocuronium over vecuronium is the short time to onset of the neuromuscular block. The two other new muscle relaxants, mivacurium and cis-atracurium, belong to the group of benzylisoquinoline muscle relaxants. Mivacurium is rapidly degraded in plasma and its principal characteristic is, hence, a short duration of action. Cis-atracurium is one of the 10 stereoisomers of atracurium. While its action is similar to that of atracurium, it does not release histamine and its administration is not accompanied by marked changes in blood pressure or heart rate. Even the simple tactile monitoring of the neuromuscular transmission enables the clinician to adjust the doses of these and other muscle relaxants to the needs of individual patients. Precise adjustment of the doses of muscle relaxants contributes to their safer clinical use by avoiding an excessively deep and unnecessarily prolonged neuromuscular block.

BACKGROUND: The effects of induced hypothermia in cardiac surgical patients are not yet fully understood. Despite numerous studies on the effects of acid-base management on organ blood flow, only little information is available on the effects of alpha-stat versus pH-stat management on systemic haemodynamics. We therefore compared the effect of alpha-stat and pH-stat acid-base management on systemic haemodynamics in a prospective, controlled, cross-over study. METHODS: Twenty patients undergoing coronary artery bypass surgery were included in the study. Cardiac output was measured by thermodilution. Cardiac index and systemic vascular resistance were calculated according to standard formulae. Measurements were performed under hypo- and hypercapnia after induction of anaesthesia. Measurements were repeated at the end of two 30-min periods of pH-stat and alpha-stat acid-base management, respectively. RESULTS: Systemic vascular resistance at the lower PaCO2-levels (hypocapnia and alpha-stat, respectively) was significantly higher than those at the higher level (hypercania and pH-stat, respectively). The periods of different PaCO2-levels were comparable with respect to haematocrit, blood viscosity and temperature. Systemic vascular resistance was not significantly different from the control period. CONCLUSIONS: This study demonstrates that during hypothermic cardiopulmonary bypass, systemic vascular resistance under alpha-stat acid-base management is higher than under pH-stat management. As obvious from measurements during the control period, this finding can be completely explained by the difference in PaCO2.

BACKGROUND: Reported results for thyroid nodule fine-needle aspiration (FNA) cytology mainly originate from tertiary centers. However, thyroid nodule FNA cytology is mainly performed in primary care settings for which the distribution of FNA Bethesda categories and their respective malignancy rates are largely unknown. Therefore, this study investigated FNA cytology malignancy rates of a large primary care setting to determine to what extent current evidence-based strategies for the malignancy risk stratification of thyroid nodules are applied and applicable in such primary care settings. METHODS: In a primary care setting, 9460 FNAs of thyroid nodules were retrospectively analyzed from 8380 patients evaluated by one cytologist (I.R.) during a period of two years. The 8380 FNA cytologies were performed by 64 physicians in different private practices throughout Germany in primary care settings. RESULTS: The cytopathologic results were classified according to the Bethesda System as non-diagnostic in 19%, cyst/cystic nodule in 21%, benign (including thyroiditis) in 48%, atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) in 6%, follicular neoplasms/suspicious for follicular neoplasm (FN/SFN) in 4%, suspicious for malignancy (SFM) in 1%, and malignant in 1%. The proportion of patients proceeding to surgery or with a follow-up of at least one year and the observed risks of malignancy were 22%/8% for AUS/FLUS, 69%/17% for FN/SFN, 78%/86% for SFM, and 71%/98% for malignant. For 112 cytologically suspicious and malignant FNAs, there were 102 true positives and 10 false positives, considering histology as gold standard. CONCLUSION: At variance with other data mostly originating from tertiary centers, these data demonstrate low percentages for malignant, SFM, FN/SFN, and AUS/FLUS, and high percentages for cysts/cystic nodules in this primary care setting in Germany. The risks of malignancy for malignant, SFM, AUS/FLUS, and FN/SFN FNA cytologies are according to Bethesda recommendations.

INTRODUCTION: A minimal documentation system (MIDOS) has been developed for self-assessment of pain and other symptoms by the patients on palliative care units. To decrease the administrative burden and thereby increase the acceptance of the system an electronic database was developed to facilitate data entry and documentation. SYSTEM: The database is based on Microsoft Access. Screen masks are used for navigation and data entry. According to the type of data items may be chosen in checklists or pull-down menus or entered as free text. The main menu documents personal data from the patient. Submenus can be reached from the main screen mask. Submenus included are the core documentation of the working group of the German Ministry of Health, the German versions of the Brief Pain Inventory, the quality of life questionnaire SF-12 and the Mini Mental State Examination for assessment of cognitive impairment. Data from these instruments may be assessed repeatedly for the same patient. Documentation of follow-up consultations include self-assessment of pain and other symptoms by the patient (MIDOS) and the analgesic regimen. These informations should be documented for each consultation. CONCLUSION: This data base was used in two trials on the palliative care unit of the university of Cologne, confirming data safety and convenience of the programme. We recommend the use of this data base in combination with MIDOS and the core documentation for routine assessment on the palliative care ward.