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Background: Much research is currently devoted to polypharmacy, but interventional studies often fail to significantly improve patient-relevant outcomes or just measure surrogate parameters. Interventions and their settings are often complex, and a wide range of factors affect results. The aim of the AdAM study is to reduce hospitalization and death by requiring general practitioners (GPs) to use a computerized decision-support system (CDSS). The study will undergo a process evaluation to identify relevant factors for successful implementation and to assess whether the intervention was implemented as intended.Research questions: We will assess implementation (reach, fidelity, dose, tailoring) by asking the following questions: (1) Who took part in the intervention, i.e., the proportion of GPs that used the CDSS, and the proportion of patients that were enrolled by them? Information on the characteristics of GPs and patients will also be collected. (2) How many and what type of medication alerts were handled by the GPs? (3) Was the intervention implemented as intended? (4) On what days did GPs use the intervention tool? We will conduct subgroup analyses to all questions, including time effects to account for software improvements over time.Methods: The process evaluation is part of a stepped wedge cluster-randomized controlled trial. Characteristics of practices, GPs and patients using the CDSS will be compared with the non-participating population. CDSS log data will be analyzed to evaluate how the number of medication alerts changed between baseline and two months later and identify the kind of medication alerts that are given highest priority. The comparison of enrolled patients on weekdays vs weekends will shed light on whether GPs use the CDSS in the absence or presence of patients. All outcomes will be presented using descriptive statistics, and significance tests will be used to identify any associations between them.Discussion: This study protocol is the basis for conducting the analyses of the log data-based process evaluation. By providing insight into the way GPs conduct medication reviews, the evaluation will provide a context to the trial results and support their interpretation. The evaluation relies on the proper documentation of what the CDSS was used for, which may limit its explanatory power.Trial registration: ClinicalTrials.gov, NCT03430336. Registered on February 6, 2018. https://clinicaltrials.gov/ct2/show/NCT03430336

Um die Schlaganfallversorgung zu optimieren, wurden in Deutschland in den letzten Jahren verschiedene qualitätsfördernde Maßnahmen (qfM) in regional unterschiedlichem Maß eingeführt. Ob sich diese Maßnahmen über die Jahre flächendeckend etabliert haben, ist unklar.Für die strukturbezogenen Analysen der Schlaganfallversorgung in Deutschland wurden alle relevanten dokumentierten Schlaganfälle (ICD-10) aus den Qualitätsberichten (QB) deutscher Krankenhäuser und eine repräsentative Stichprobe von Krankenversicherungsdaten (AOK) im Zeitraum von 2006 (QB)/2007 (AOK) bis 2017 verwendet. Diese Informationen wurden u. a. durch Angaben zu zertifizierten Stroke Units der Deutschen Schlaganfall-Gesellschaft (DSG) und Daten zur Führung von regionalen Schlaganfall-Registern der Arbeitsgemeinschaft Deutschsprachiger Schlaganfall-Register (ADSR) ergänzt. Zur Verfolgung der Veränderungen des Versor-gungsgeschehens im deutschen Bundesgebiet wurden die Daten mit geografischen Daten (Bundesamt für Kartographie und Geodäsie) verknüpft. Es erfolgten univariate Analysen der Daten und eine Trend-Analyse der verschiedenen qfM im Jahresverlauf (Konkordanzkoeffizient nach Kendall).Die QB Analysen zeigten einen Anstieg kodierter Schlaganfälle in Krankenhäusern mit qfM um 14-20%. In 2006 wurden 80% der Schlaganfälle (QB) in einem Krankenhaus mit min. einer qfM kodiert, in 2017 95%. Diese Entwicklungen spiegelten sich auch in den AOK-Routinedaten wider, wobei in 2007 89% und in 2017 97% der Patient:innen unter mindestens einer qfM behandelt wurden. Dabei waren in 2007 bei 55% der behandelnden Krankenhäuser qfM vorhanden, in 2017 bei 72%.Patient:innen werden inzwischen signifikant häufiger in Krankenhäusern mit Spezialisierung auf die Schlaganfallversorgung behandelt. Auch die verschiedenen qfM haben sich im Laufe der Jahre im gesamten Bundesgebet verbreitet, jedoch existieren noch Versorgungslücken, die geschlossen werden sollten, damit in Zukunft alle Patient:innen qualitativ hochwertig behandelt werden können.In order to optimize stroke care, various quality-enhancing measures (qfM) have been introduced in Germany in recent years to varying degrees across regions, with the aim of achieving the best possible quality of care. It is unclear whether these measures have become established nationwide over the years.For the structural analyses of stroke care in Germany, all relevant documented strokes (ICD-10) from the quality reports (QB) of German hospitals and a representative sample of health insurance data (AOK) for the period from 2006 (QB)/2007 (AOK) to 2017 were used. This information was supplemented by data on certified stroke units from the German Stroke Society (DSG) and data on the maintenance of regional stroke registries from the Working Group of German-Speaking Stroke Registers (ADSR), among others. To track changes in patterns of care in Germany, the data were linked with geographic data (Federal Agency for Cartography and Geodesy). Univariate analyses of the data and a trend analysis of the different qfM over the year (Kendall concordance coefficient) were performed.The analyses (QB) showed an increase in coded strokes in hospitals with qfM between 14-20%. In 2006, 80% of strokes (QB) were coded in hospitals with at least one qfM and 95% in 2017. Comparing years, AOK data showed similar trends: in 2007, 89% of patients were treated in hospitals with at least one qfM and 97% in 2017. In 2007, 55% of treating hospitals had qfM and 72% in 2017.Meanwhile, patients are more often treated in hospitals that specialise in stroke care. In addition, the various qfM have spread across the nation over the years, but there are still gaps in care that should be addressed to ensure quality care for all patients in the future.

BACKGROUND: Quality assurance for acute in-hospital care in Germany is based on compulsory comparisons between institutions, so-called external quality assurance (EQA). The effectiveness of EQA has not yet been adequately studied. The purpose of the QUASCH project, which is supported by the Innovation Fund of the Federal Joint Committee, is to investigate the association between EQA and health care outcomes, specifically with respect to stroke. METHODS: The analyses were based on data from 379 825 patients insured by the AOK health insurance fund who were acutely admitted to a hospital because of stroke over the period 2007–2017. Data on 47 659 patients were derived from EQA documentation in the state of Hesse, in which stroke EQA had already been introduced in 2003; data on the remaining 332 166 patients were from other federal states, where 117 734 of these patients had been treated under EQA conditions. The association of EQA with mortality over the period of observation was analyzed by multivariate Cox regression, with the following covariates: age, sex, comorbidities, time period of occurrence, nursing care level, type of stroke, socio-economic deprivation in the region of origin, and treatment in a stroke unit. RESULTS: Compared to treatment without EQA, mortality risk under EQA in the state of Hesse was significantly lower (hazard ratio [HR]: 0.93; 95% confidence interval: [0.92; 0.95]). The reduction in mortality risk with EQA was somewhat lower in the other federal states (HR: 0.96 [0.95; 0.97]). Treatment in a stroke unit was associated with a mortality risk that was lower still (HR: 0.86 [0.85; 0.87]). Mortality risk rose with age, comorbidities, and need for nursing care; it was lower in women and in persons whose stroke occurred in a later period. CONCLUSION: Quality assurance measures are associated with lower mortality risk after stroke. The concentration of care in specially qualified institutions is associated with stronger effects than EQA alone.

SARS-CoV-2 infection rates in children and adolescents are often underestimated due to asymptomatic or oligosymptomatic infections. Seroprevalence studies can reveal the magnitude of “silent” infections in this age group and help to assess the risk of infection for children but also their role in spreading the disease. In total, 2045 children and their parents from the Ruhr region were finally included after the exclusion of drop-outs. Seroconversion rates among children of all age groups increased from 0.5% to 8% during the study period and were about three to fourfold higher than the officially registered PCR-based infection rates. Only 41% recalled symptoms of infection, 59% were asymptomatic. In 51% of the infected children, at least one parent also developed SARS-CoV-2 antibodies. Depending on local incidences, the rates of seroconversion rose to different levels during the study period. Although the dynamics of infection within the study cohort mirrors local incidence, the figure of SARS-CoV-2 infections in children and adolescents appears to be high. Reported contact with SARS-CoV-2-infected individuals in the same household carries a high risk of infection.

IntroductionSocioeconomic and ethnic background have been discussed as possible risk factors for SARS-CoV-2 infections in children. Improved knowledge could lead way to tailored prevention strategies and help to improve infection control.MethodsObservational population-based cohort study in children (6mo. - 18 ys.) scheduled for legally required preventive examination and their parents in a metropolitan region in Germany. Primary endpoint was the SARS-CoV-2 seroconversion rate during study period. Risk factors assessed included age, pre-existing medical conditions, socioeconomic factors, and ethnicity.Results2124 children and their parents were included. Seroconversion rates among children in all age groups increased by 3-4-fold from 06/2020 to 02/2021. Only 41% of seropositive children were symptomatic. In 51% of infected children at least one parent was also SARS-CoV-2 positive.Low level of parental education (OR 3.13 (0.72-13.69)) significantly increased the risk of infection. Of the total cohort, 38.5% had a migration background. Specifically, 9% were of Turkish and 5% of Middle Eastern origin. These children had the highest risk for SARS-CoV-2 infections (OR 6.24 (1.38-28.12) and 6.44 (1.14-36.45) after adjustment for other risk factors.DiscussionSeroprevalence of SARS-CoV-2 infections in children increased by 3-4-fold within the study period. Frequently, more than one family member was infected. Children from families with lower socioeconomic status were at higher risk. The highest risk for SARS-CoV-2 infection was identified in families with Turkish or Middle Eastern background. Culture sensitive approaches are essential to improve infection control and serve as a blueprint for vaccination strategies in this population.Trial RegistrationBMBF funding registration 01KI20173 (Corkid)

OBJECTIVES Here we asked, whether contrast enhanced ultrasound (CEUS) enables to judge early treatment response in malignant lymphoma as a potential guidance for further treatment. METHODS From May 2017 to May 2018, 21 patients with histologically confirmed diagnosis of lymphoma were examined by B-mode ultrasound (B-US) and CEUS at fixed early time points after commencing therapy (days [d] 0, 15 and 30 after therapy start) and contrast enhancement patterns in target lymphoma lesions were quantified using Bracco-VUE Box® (DCE-US). To estimate the potential value of CEUS-enhancement patterns for early response prediction, patients were grouped according to their best achieved actual response into complete remission (CR) patients, partial remission (PR) patients or progressive disease (PD) patients. RESULTS Between d0, d15 and d30, CR-patients showed a median lymphoma shrinking by 34% in B-US. PD-patients experienced a median lymphoma size reduction by 44% on day 15, but lymphoma mass again increased by 20% between d15 and d30. In contrast, the median CEUS enhancement intensity, as assessed by the area under the curve (AUC) was increasing at d15 in CR and PD patients (CR to 152%, PD: to 126%), but decreased at d30 to 14% in CR patients and 22% in PD patients. CONCLUSIONS While early response assessment using B-US might be useful to predict treatment response in lymphoma, CEUS and DCE-US-although often feasible-do not provide additional value in this regard.

Nutrients 13(7), 2356 (2021). doi:10.3390/nu13072356 special issue: "Special Issue "Current Understanding of Vitamin D in Chronic Diseases, Acute Respiratory Infections and All-Cause Mortality" / Special Issue Editors: Prof. Dr. Sara Gandini, Guest Editor; Dr. Harriet Johansson, Guest Editor; Dr. Davide Serrano, Guest Editor; Prof. Dr. Sara Raimondi, Guest Editor; Dr.ssa Patrizia Gnagnarella, Guest Editor", Published by MDPI, Basel

BACKGROUND: Medications with an unfavorable risk–benefit profile in the elderly, and for which there are safer alternatives, are designated as potentially inappropriate medications (PIM). The RIME trial (Reduction of Potentially Inappropriate Medication in the Elderly) was based on PRISCUS, a list of PIM that was developed in 2010 for the German pharmaceuticals market. In this trial, it was studied whether special training and the PRISCUS card could lessen PIM and undesired drug–drug interactions (DDI) among elderly patients in primary care. METHODS: A three-armed, cluster-randomized, controlled trial was carried out in two regions of Germany. 137 primary care practices were randomized in equal numbers to one of two intervention groups—in which either the primary care physicians alone or the entire practice team received special training—or to a control group with general instructions about medication. The primary endpoint was the percentage of patients with at least one PIM or DDI (PIM/DDI) per practice. The primary hypothesis was that at 1 year this endpoint would be more effectively lowered in the intervention groups compared to the control group. RESULTS: Among 1138 patients regularly taking more than five drugs, 453 (39.8%) had at least one PIM/DDI at the beginning of the trial. The percentages of PIM/DDI at the beginning of the trial and 1 year later were 43.0% and 41.3% in the intervention groups and 37.0% and 37.6% in the control group. The estimated intervention effect of any intervention (69 practices) versus control (68 practices) was 2.3% (p = 0.36), while that of team training (35 practices) versus physician training (34 practices) was 4.3% (p = 0.22). CONCLUSION: The interventions in the RIME trial did not significantly lower the percentage of patients with PIM or DDI.

Cough and wheezing are the predominant symptoms of acute bronchitis. Hitherto, the evaluation of respiratory symptoms was limited to subjective methods such as questionnaires. The main objective of this study was to objectively determine the time course of cough and wheezing in children with acute bronchitis. The impact of nocturnal cough on parent’s quality of life was assessed as secondary outcome. In 36 children (2–8 years), the frequency of nocturnal cough and wheezing was recorded during three nights by automated lung sound monitoring. Additionally, parents completed symptom logs, i.e., the Bronchitis Severity Score (BSS), as well as the Parent-proxy Children’s Acute Cough-specific Quality of Life Questionnaire (PAC-QoL). During the first night, patients had 34.4 ± 52.3 (mean ± SD) cough epochs, which were significantly reduced in night 5 (13.5 ± 26.5; p

Parents whose children are affected by systemic diseases, anomalies, deformities, or further orthopedic defective positions use the Internet to increase their knowledge. However, there have been few studies that focus, as this one does, on Internet enquiries done before the parents contact the pediatric orthopedic surgeon. This study analyzed data gathered through a standardized questionnaire on general habits of Internet use, parents' hardware, age, and educational background of the parents. A total of 521 questionnaires were completed for a response rate of 96%. One-quarter of parents (n = 127) attended the consultation because of a gait anomaly or foot deformity, followed by children with DDH (20%, n = 99), clubfoot (9%, n = 47), and scoliosis (6%, n = 29). Parents of children with clubfoot were especially likely to look for health information online (84%, n = 38), followed by parents of children with scoliosis (69%, n = 20), with DDH (67%, n = 66), and with foot deformity/gait anomaly (49%, n = 62). Most people (97%, n = 295) using the Internet for health research purposes made use of a search engine. Concerning use of social media, respondents with clubfoot children were the most numerous (38%, n = 18). There were 35 parents who intended to discuss the results of their Internet research with the pediatric orthopedic surgeon. Most (84%, n = 254) of the respondents who used the Internet for health research planned to do so again.Conclusion: This study documented that the Internet is an important and popular source of information for parents or caregivers in the field of pediatric orthopedics.Level of evidence: Level II; prospective study What is known: •Parents and caregivers often search the Internet for information, particularly before an upcoming operation in the field of orthopedic disorders. What is new: •This study provides recent data on parental Internet research in a large study population.

Background Internet Use Disorders (IUD) cover a range of online-related behavioral addictions, which are acknowledged and strengthened by the inclusion of (online) gaming disorder in the ICD-11 by the World Health Organization. Internet-based telemedicine interventions offer the possibility to reach out for individuals with IUD where the disorder emerges, in order to enhance their motivation to change their Internet use behavior. Methods In the course of the short-term telemedicine motivation-based intervention, adult participants took part in two webcam-based counselling sessions based on Motivational Interviewing techniques. Two weeks after the first webcam-based counselling session the second took place. Participants completed questionnaires regarding the motivation to change their Internet use behavior (iSOCRATES) and symptoms of IUD (s-IAT) at three times of measurement: t0 (pre-intervention), t1 (mid-intervention) and t2 (post-intervention). Results 73 affected individuals (83.6% male, average age 35 years (SD = 12.49) took part in the whole intervention including the questionnaire-based post intervention survey (t2). Over the course of the telemedicine intervention, a significant increase in the motivation to change with regard to the own Internet use behavior as well as a significant reduction in the symptom severity of an IUD and duration of Internet use (reduction of 2 hrs/d) were shown. Conclusion The telemedicine pilot study shows that online-based consultation can be effective and helpful for individuals with IUD. Therefore, such a telemedicine intervention may be a suitable extension to the already existing analogous care system.

BACKGROUND Current in vitro allergen-specific IgE (sIgE) detection assays measure IgE against allergen extracts or molecules in a single- or multiplex approach. Direct comparisons of the performance of such assays among young children with common presentations of allergic diseases regardless of sensitization status are largely missing. OBJECTIVES The aim of this study was a comparison of the analytical and diagnostic performance for common clinical questions of three commonly used technologies which rely upon different laboratory methodologies among children of the All Age Asthma (ALLIANCE) cohort (clinicaltrials.gov: NCT02496468). METHODS Sera from 106 paediatric study participants (mean age 4 years) were assessed for the presence of sIgE by means of the ImmunoCAP™ sx1 and fx5 mixes, the ImmunoCAP ISAC™ 112 microarray and a Euroline™ panel. RESULTS Total and negative concordance was high (>82%->89%), while positive concordance varied considerably (0%-100%) but was also >50% for the most common sensitizations analysed (house dust mite and birch). All three test systems showed good sensitivity and specificity (AUC consistently > 0.7). However, no significant differences with regard to identifying sIgE sensitizations associated with symptoms in children with suspected pollen- or dust-triggered wheeze or presenting with symptoms of allergic rhinoconjunctivitis or food allergy were detected. Extending the number of allergens did not change the similar performance of the three assay systems. CONCLUSION AND CLINICAL RELEVANCE Among young children, the three sIgE assays showed good analytical and diagnostic concordance. Our results caution that the identification of larger numbers of sensitizations by more comprehensive multiplex approaches may not improve the clinical utility of sIgE testing in this age group.

Background Brain-derived neurotrophic factor (BDNF) influences brain plasticity and feeding behaviour, and it has been linked to anorexia nervosa in numerous studies. Findings in mostly adult patients point to reduced serum BDNF levels in the acute stage of anorexia nervosa and rising levels with weight recovery. However, it is unclear whether this increase leads to normalization or supranormal levels, a difference that is potentially important for the etiology of anorexia nervosa and relapse. Methods We measured serum BDNF at admission (n = 149), discharge (n = 130), 1-year follow-up (n = 116) and 2.5-year follow-up (n = 76) in adolescent female patients with anorexia nervosa hospitalized for the first time, and in healthy controls (n = 79). We analyzed associations with body mass index, eating disorder psychopathology and comorbidities. Results Serum BDNF was only nominally lower at admission in patients with anorexia nervosa compared to healthy controls, but it increased continuously and reached supranormal levels at 2.5-year follow-up. BDNF was inversely associated with eating disorder psychopathology at discharge and positively associated with previous weight gain at 1-year follow-up. Limitations We compensated for attrition and batch effects using statistical measures. Conclusion In this largest longitudinal study to date, we found only nonsignificant reductions in BDNF in the acute stage of anorexia nervosa, possibly because of a shorter illness duration in adolescent patients. Supranormal levels of BDNF at 2.5-year follow-up could represent a pre-existing trait or a consequence of the illness. Because of the anorexigenic effect of BDNF, it might play an important predisposing role for relapse and should be explored further in studies that test causality.

Background: Diagnosis and treatment of paediatric tuberculosis resistant to both isoniazid and rifampicin (MDR-pTB) remain challenging due to paucibacillary disease, low sensitivity and specificity of diagnostic tools and frequently changing guidelines Aims and objective: This study aimed to describe epidemiology, clinical characteristics and outcome of MDR-TB among children and adolescents in Germany. Methods: We collected all cases of MDR-pTB registered in Germany from 2010 to 2020 and compared their data to an adequate control sample with drug-sensitive TB. Results: 52 subjects with MDR-pTB (24 active MDR-TB, 28 MDR-LTBI) and 56 controls were included. The annual incidence of MDR-TB rose from two in 2010 to nine in 2020. Time to diagnosis was longer in MDR-pTB compared to drug-sensitive TB (43 vs. 8 days, p Conclusions: Early diagnosis, identification of potential MDR index, appropriate treatment and follow-up are essential in MDR-pTB. Therefore, better cooperation between clinics and public health care is required in Germany. In children with an MDR-TB index case or in those born in a MDR high-incidence country, bacteriological confirmation including PCR-based susceptibility testing should always be initiated. The individual drug regimen has to be adapted to the patients’ or index’ susceptibility testing results.

Tumor-cell infiltration is a major obstacle to successful therapy for brain tumors. Membrane-type matrix metalloproteinases (MT-MMPs), a metzincin subfamily of six proteases, are important mediators of infiltration. The cellular source of MT-MMPs and their role in glioma biology, however, remain controversial. Thus, we comprehensively analyzed the expression of MT-MMPs in primary brain tumors. All MT-MMPs were differentially expressed in primary brain tumors. In diffuse gliomas, MT-MMP1, -3, and -4 were predominantly expressed by IDH1mutated tumor cells, while macrophages/microglia contributed significantly less to MT-MMP expression. For functional analyses, individual MT-MMPs were expressed in primary mouse p53&minus, /&minus, astrocytes. Invasion and migration potential of MT-MMP-transduced astrocytes was determined via scratch, matrigel invasion, and novel organotypic porcine spinal slice migration (OPoSSM) and invasion assays. Overall, MT-MMP-transduced astrocytes showed enhanced migration compared to controls. MMP14 was the strongest mediator of migration in scratch assays. However, in the OPoSSM assays, the glycosylphosphatidylinositol (GPI)-anchored MT-MMPs MMP17 and MMP25, not MMP14, mediated the highest infiltration rates of astrocytes. Our data unequivocally demonstrate for the first time that glioma cells, not microglia, are the predominant producers of MT-MMPs in glioma and can act as potent mediators of tumor-cell infiltration into CNS tissue. These proteases are therefore promising targets for therapeutic interventions.

Simple Summary Most primary brain tumors infiltrate the surrounding brain even before the time of diagnosis and therefore cannot be removed completely. Matrix metalloproteases can degrade the extracellular proteins of the brain and thereby allow for the brain infiltration of glioma cells. Here, we demonstrate that tumor cells are the major source of several metalloproteases and as such responsible for the malignant behavior of gliomas. Our findings suggest that, controlling metalloproteases might be a promising therapeutic avenue in the treatment of glioma. Abstract Tumor-cell infiltration is a major obstacle to successful therapy for brain tumors. Membrane-type matrix metalloproteinases (MT-MMPs), a metzincin subfamily of six proteases, are important mediators of infiltration. The cellular source of MT-MMPs and their role in glioma biology, however, remain controversial. Thus, we comprehensively analyzed the expression of MT-MMPs in primary brain tumors. All MT-MMPs were differentially expressed in primary brain tumors. In diffuse gliomas, MT-MMP1, -3, and -4 were predominantly expressed by IDH1mutated tumor cells, while macrophages/microglia contributed significantly less to MT-MMP expression. For functional analyses, individual MT-MMPs were expressed in primary mouse p53−/− astrocytes. Invasion and migration potential of MT-MMP-transduced astrocytes was determined via scratch, matrigel invasion, and novel organotypic porcine spinal slice migration (OPoSSM) and invasion assays. Overall, MT-MMP-transduced astrocytes showed enhanced migration compared to controls. MMP14 was the strongest mediator of migration in scratch assays. However, in the OPoSSM assays, the glycosylphosphatidylinositol (GPI)-anchored MT-MMPs MMP17 and MMP25, not MMP14, mediated the highest infiltration rates of astrocytes. Our data unequivocally demonstrate for the first time that glioma cells, not microglia, are the predominant producers of MT-MMPs in glioma and can act as potent mediators of tumor-cell infiltration into CNS tissue. These proteases are therefore promising targets for therapeutic interventions.

BackgroundSubjects with chronic kidney disease are at increased risk for contrast-induced acute kidney injury (CI-AKI). Risk stratification is traditionally based on glomerular filtration rate (GFR) and proteinuria. The present trial examines, whether tubular and inflammatory biomarkers are able to identify subjects at increased risk as well.MethodsWe performed a prospective study in 490 patients undergoing coronary angiography. An increase of serum creatinine concentration ≥ 0.3 mg/dl from baseline to day 2-3 was defined as primary endpoint (CI-AKI). Urinary neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and calprotectin were assessed < 24h before coronary angiography. Prognostic accuracy was assessed by receiver operating characteristics (ROC) calculations.Results30 (6.1%) patients suffered from CI-AKI (27 AKIN stage I, 3 AKIN stage II, 0 AKIN stage III). Those subjects who developed CI-AKI had 3.1 fold higher baseline urinary NGAL/creatinine ratios than those without CI-AKI (60.8 [IQR 18.7-93.1] μg/mg vs. 19.9 [IQR 12.3-38.9] μg/mg, p = 0.001). In those subjects without clinically overt CKD (eGFR > 60 ml/min, urinary albumin creatinine ratio 0.05 each). ROC analyses revealed an area under the curve (AUC) of 0.68 (95% CI 0.60-0.81) for NGAL/creatinine. An NGAL/creatinine ratio < 56.4 μg/mg has a negative predictive value of 96.5%.ConclusionsThe present study is the largest investigation on the use of urinary biomarkers for CI-AKI risk stratification so far. It shows that NGAL provides prognostic information beyond the glomerular biomarkers eGFR and proteinuria.

Background Implementation of advance care planning (ACP) is proceeding in the western world and often recognised as a sufficient approach to ensure patients’ wishes for end of life (EoL) care. There is evidence that patient related outcomes are improved. However, information about the impact of ACP on quality of life (QoL) in palliative cancer patients is missing. Methods This randomised controlled trial investigates the efficacy and effectiveness of a collaborative ACP (cACP) intervention in palliative cancer patients and their care givers by comparing three groups: 1. cACP-Intervention; 2. Supportive intervention 3. Treatment as usual. The cACP-intervention consists of four sessions (two with the patient alone, one with the care giver alone, one together) that address potential barriers to discuss end of life issues (e.g. negative expectations concerning EoL issues and ACP) and two regular ACP sessions. Primary endpoint is the patient health-related QoL (FACIT-PAL). Secondary endpoints are general QoL; distress; acceptance; depressiveness; evaluation of the intervention; care-givers: heath-related and general QoL. Patients’ QoL is evaluated every second month for one year. In the event of the patients death, care-givers are asked to answer questions about concordance of advance care planning with actual care and the patients quality of dying. Results Until 11/18, 75 patients have been randomized, 13 patients finished the intervention, 21 patients died, denial rate is at approx. 55%. Conclusion This study tries to implement ACP in a palliative cancer setting in Germany. The efficacy and effectiveness of a novel collaborative ACP intervention are evaluated.

Veno-occlusive disease (VOD) is a severe complication of allogeneic stem cell transplantation (allo-SCT). Its diagnosis is difficult, and ultrasound (US) has not been proven to be of additional diagnostic value. In the work described here, we prospectively analyzed the hepatic contrast-enhanced ultrasound (CEUS) pattern before and after allo-SCT and correlated these results with the pre-allo-SCT VOD risk factors, clinical VOD findings and conventional US findings. Thirty consecutive patients who underwent allo-SCT and had at least one VOD risk factor were studied. B-Mode US and CEUS were longitudinally performed at defined time points before and after allo-SCT. The 1-min hepatic enhancement (OMHE) in CEUS was standardized to splenic enhancement and quantified using optical density (OD) measurement software. A hypo-OMHE was arbitrarily defined as pathologic (pOMHE) if the OD of the liver was less than 90% compared with the mean splenic OD. Twenty-one patients (70%) had a pOMHE, the occurrence of which peaked at day 10 after allo-SCT. The number of pre-treatment VOD risk factors significantly differed between the pathologic and non-pathologic OD groups. Together, patients undergoing allo-SCT frequently exhibit a pathologic hepatic CEUS pattern, which can be quantified by OD measurement and is suggestive of pre-clinical VOD or other hepatic pathologies.

Background Haemodynamic instability during the induction of anaesthesia and surgery is common and may be related to hypovolaemia caused by pre-operative fasting or chronic diuretic therapy. The aim of our prospective, controlled, randomized study was to test the hypothesis that a predefined fluid bolus given prior to general anaesthesia for minor surgery would increase haemodynamic stability during anaesthetic induction. Methods Two hundred and nineteen fairly healthy adult patients requiring minor surgery were enrolled. All received standard treatment, including a pulse contour analysing device for non-invasive measurement of cardiac index. Infusion therapy was started in all patients at induction. The intervention group (106 patients) was randomized to receive an additional fluid bolus of 8 mL/kg Ringer's acetate solution before the induction of anaesthesia. The primary endpoint was the incidence of haemodynamic instability, defined as a significant reduction of blood pressure or cardiac index during induction of anaesthesia. Results The interventional group had a lesser incidence of haemodynamic instability during induction (41.5% vs 56.6%, P = .025). This group also had higher cardiac index, stroke volume index, systolic and mean blood pressure and a greater left ventricular end-diastolic area. Conclusions A fluid bolus prior to anaesthesia reduced the incidence of haemodynamic instability during induction of general anaesthesia. The total fluid volume was slightly greater in the intervention group compared to the control group (1370 ± 439 mL vs 1219 ± 483 mL, P = .007). We conclude that a defined fluid bolus can help stabilizing haemodynamics in patients undergoing general anaesthesia.

The retrograde approach (RP) to nerve identification is a method seldom used in parotid surgery. A systematic review comparing this method to the standard anterograde approach (AP) with respect to facial nerve palsy (FNP) does not currently exist. In a meta-analysis according to the PRISMA statement, eight publications, including one randomized controlled trial, were selected. The primary aim was to compare the temporary and permanent FNP resulting from the two dissection methods. Facial nerve function was graded according to the House–Brackmann Scale. The secondary goal was a comparison of the cut–suture times (CST), the volume of healthy tissue (VHT) dissected, the rates of postoperative hematoma (PH), and postoperative infection (PI). Temporary FNP was noted in 18.2% in the RP group as well as in 34.4% in the AP group. Permanent FNP occurred in 0.9% RPs and 2.4% APs. According to the mixed-effect logistic regression model, there was no significant difference between the two groups in the pooled odds ratio (OR) for either temporary [OR 2.64, 95% confidence interval (CI) 0.97–7.21] or permanent FNP (OR 4.31, 95% CI 0.44–42.28). The CST was significantly shorter in the RP group (p = 0.005), with a significantly smaller VHT dissected (p

MPFL reconstruction is widely and successfully used for treating patella instability, either as a standalone procedure or in combination. Although different techniques allow for MPFL reconstruction, the use of a free tendon graft is one of the most commonly used. The phenomenon of tunnel widening or tunnel enlargement is well described in ACL reconstruction, but so far only little effort has been put into evaluating this phenomenon after MPFL reconstruction. Patients who received an MPFL reconstruction with a free gracilis tendon graft were identified by review of patient files. Additional clinical examination and magnetic resonance imaging were performed to assess tunnel enlargement and clinical outcome. Fifty-one knees of 49 patients (34 female, 17 male) with a mean follow-up of 3.0 ± 1.4 years were included in this study. Mean age at the time of surgery was 22.6 ± 8.5 years. Mean Tegner score decreased from preoperative 5.3 ± 2.0 to 4.0 ± 1.4 postoperative. Postoperative IKDC and Kujala scores were 74 ± 16 and 80 ± 15, respectively. Twenty-three patients showed a tunnel enlargement at follow-up examination. Of these 23 patients, 20 showed a tunnel that was positioned too proximal, whereas only 13 of the 28 patients showing no enlargement had a tunnel that was positioned too proximal (p = 0.0033). Interestingly, patients showing a tunnel enlargement at follow-up examination also showed significantly better Kujala (84 ± 12 vs. 75 ± 16; p = 0.03) and IKDC scores (80 ± 7 vs. 70 ± 19; p = 0.02) when compared to the non-enlarged group. Tunnel enlargement after MPFL reconstruction with a free gracilis tendon graft seems to be connected to mechanical overload due to a proximal malposition of the femoral tunnel. Interestingly, this did not influence clinical outcome as patients with tunnel enlargement showed better Kujala and IKDC scores.

Objectives Focused transthoracic echocardiography (TTE) is used perioperatively for surgical patients. Intraoperative application of TTE is feasible, but its benefits remain unclear. The intention of this study was to investigate the effect of intraoperative TTE on the management of high-risk noncardiac surgery patients. Design A prospective interventional study. Setting Single-center university hospital. Participants Fifty consecutive hemodynamically unstable high-risk patients anesthetized for noncardiac surgery. Interventions Focused TTE was performed on hemodynamically unstable anesthetized patients whenever circulatory instability (defined as hypotension or low cardiac output) occurred intraoperatively. A cardiac output monitoring system using pulse contour analysis was established before induction of anesthesia. The intended therapy for stabilizing the patient was documented; however, the management actually administered was guided by the results of the TTE. Differences between the 2 lines of management were documented and analyzed. Measurements and Main Results Intraoperative TTE was applied successfully in all 50 unstable patients. In 33 patients (66%, 95% confidence interval, 52.11-77.61) TTE led to a change of management. Altogether, 82 episodes of hemodynamic instability were recorded, including 38 episodes (46.34%, 95% confidence interval, 35.95-57.06) in which TTE led to a change of treatment. The most common pathologic finding was hypovolemia (66%); in contrast, in 22%, right-heart overload or right-heart failure (4%) was detected. Conclusions Focused TTE by anesthesiologists can provide new information that may alter the hemodynamic management of unstable high-risk noncardiac surgery patients in the operating room.

Objective High levels of expressed emotions (EE) and depressive symptoms (DS) are often found in caregivers of patients with anorexia nervosa (AN). Both parameters are considered to influence AN symptoms of the patient. Methods One hundred seventy adolescent women with AN and their caregivers were assessed at admission, discharge, at 1-year and 2.5-year follow up to evaluate AN symptoms of the patient and EE and DS of caregivers. Results The EE and DS were elevated at admission and decreased during treatment, criticism (as part of EE) exhibited again at the 2.5-year follow up. Caregivers of more severely ill patients reported significantly greater levels of EE and DS. Mothers were more affected than fathers. EE and DS were interrelated. Conclusion Caregivers of adolescent AN patients suffer from elevated levels of EE and DS. Further studies are needed to examine whether therapeutic interventions to reduce caregivers' EE and DS might have a positive influence on treatment outcome. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Background Community-acquired pneumonia (CAP) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) represent a major burden of disease and death and their differential diagnosis is critical. A potential source of relevant accessible biomarkers are blood-borne small extracellular vesicles (sEVs). Methods We performed an extracellular vesicle array to find proteins on plasma sEVs that are differentially expressed and possibly allow the differential diagnosis between CAP and AECOPD. Plasma samples were analyzed from 21 healthy controls, 24 patients with CAP, and 10 with AECOPD . The array contained 40 antibodies to capture sEVs, which were then visualized with a cocktail of biotin-conjugated CD9, CD63, and CD81 antibodies. Results We detected significant differences in the protein decoration of sEVs between healthy controls and patients with CAP or AECOPD. We found CD45 and CD28 to be the best discrimination markers between CAP and AECOPD in receiver operating characteristic analyses, with an area under the curve >0.92. Additional ensemble feature selection revealed the possibility to distinguish between CAP and AECOPD even if the patient with CAP had COPD, with a panel of CD45, CD28, CTLA4 (cytotoxic T-lymphocyte-associated protein 4), tumor necrosis factor–R-II, and CD16. Conclusion The discrimination of sEV-associated proteins is a minimally invasive method with potential to discriminate between CAP and AECOPD.

Objectives Whole surgical lymph node excision (SNE) is considered the standard diagnostic method in the primary diagnosis of lymphadenopathy (LA) suspected of malignancy. Ultrasound-guided full core needle biopsy (UFCNB) offers an alternative method to SNE. This study examined the accuracy of UFCNB in the diagnosis of unexplained LA in 793 cases. Methods From January 2006 to June 2015, a total of 793 cases of LA of unknown origin received a UFCNB. The lymph nodes were located peripherally (68%) or abdominally (32%). The final diagnoses from histopathologic examinations were non-Hodgkin lymphoma (n = 245), Hodgkin lymphoma (n = 53), solid nonlymphocytic lymph node metastases (n = 359), and benign LA (n = 136). The results of the biopsies were retrospectively evaluated with regard to sensitivity, specificity, and diagnostic accuracy. Results In the total collective of 793 biopsies, the sensitivity of UFCNB was 94.4%; the specificity was 97.8%; and the diagnostic accuracy was 95.0%. In the subgroups, the following results were obtained: non-Hodgkin lymphoma (sensitivity, 97.2%), Hodgkin lymphoma (sensitivity, 88.7%), metastases (sensitivity, 93.3%), and benign LA (specificity, 97.8%). In 17 cases (2.2%), an additional rebiopsy of the lymph node was needed, and in 85 cases (10.7%), an additional SNE was performed. Conclusions Due to the diagnostic accuracy of 95.0% in the total collective, UFCNB seems to be an alternative diagnostic procedure to the standard procedure of SNE for LA of unknown origin. A prospective comparative study to definitively clarify the diagnostic value of UFCNB compared to SNE in the unexplained LA is warranted.

Aim: To demonstrate the global challenge of maternal obesity and to propose models to increase awareness and health literacy. Methods: The regional perinatal data base and the international literature were reviewed to demonstrate the rising rates of maternal overweight and obesity causing major public health problems in low and high-resourced countries. A preliminary systematic review analyzing interventions in maternal obesity and a fact box based on a recent Cochrane review on dietary interventions were performed. Results: Between 2000 and 2015, the regional rates of maternal overweight and obesity have significantly increased, and the rate of morbid maternal obesity has even doubled. Pregnant women were insufficiently informed about the health risks and international recommendations for weight gain associated with pre-pregnancy body mass index. Scientific publications and guidelines of professional boards have not yet interrupted the vicious cycle of transgenerational transfer of associated health risks for the offspring. For the first time we propose a fact box to translate the results from a Cochrane review about dietary interventions into a transparent information for health care providers and patients which could help to improve awareness. Conclusions: Improving health literacy and translating clinical science into models which are understandable by policy makers, health care providers and parents is a challenge mainly if health risks are modifiable during gestation and could prevent the increasing burden of obesity for future societies.

Background The intraoperative application of focused transthoracic echocardiography (TTE) is often considered to be restricted. Echocardiography with pocket-sized hand held ultrasound systems has been shown to be feasible in various settings. Objective The aim of this study was to investigate the feasibility of the intraoperative application of pocket-sized echocardiography and the comparison of its imaging quality and diagnostic reliability and variability with a standard ultrasound system. Methods After written informed consent, TTE was performed on 40 anaesthetised general, vascular, visceral, thoracic surgical and orthopaedic patients according to the FATE protocol: first, with a pocket-sized and second, with a high-end ultrasound system randomly by two anaesthetists. Imaging quality of four basic and three additional FATE views was rated on an established scale from 1 (impossible) to 5 (perfect). Successful TTE was defined, if one basic FATE views would be rated as grade 4 or 5 or alternatively two views as grade 3. Pathologic findings by both ultrasound devices were documented and imaging quality and pathologic findings were compared. Results All 40 patients presented acceptable imaging quality, resulting in a success rate of 1.0 (97.5%-CI 0.91-1, p= 0.015). The individual imaging ratings of each view were significantly lower with the pocket-sized system, but still showed acceptable imaging quality. With the high-end device more pathologic findings were detected (107 vs. 87), but none of the relevant or severe pathologies were overseen with the hand-held device. Conclusion The application of a pocket-sized echocardiography device for focused intraoperative TTE is feasible and can appropriate be used for the initial evaluation of relevant pathologies in the operating theatre.

Elevated serum leptin levels following rapid therapeutically induced weight gain in anorexia nervosa (AN) patients are discussed as a potential biomarker for renewed weight loss as a result of leptin-related suppression of appetite and increased energy expenditure. This study aims to analyze the predictive value of leptin levels at discharge as well as the average rate of weight gain during inpatient or day patient treatment for body weight at 1-year follow-up. 121 patients were recruited from the longitudinal Anorexia Nervosa Day patient versus Inpatient (ANDI) trial. Serum leptin levels were analyzed at referral and discharge. A multiple linear regression analysis to predict age-adjusted body mass index (BMI-SDS) at 1-year follow-up was performed. Leptin levels, the average rate of weight gain, premorbid BMI-SDS, BMI-SDS at referral, age and illness duration were included as independent variables. Neither leptin levels at discharge nor rate of weight gain significantly predicted BMI-SDS at 1-year follow-up explaining only 1.8 and 0.4 % of the variance, respectively. According to our results, leptin levels at discharge and average rate of weight gain did not exhibit any value in predicting weight at 1-year follow-up in our longitudinal observation study of adolescent patients with AN. Thus, research should focus on other potential factors to predict weight at follow-up. As elevated leptin levels and average rate of weight gain did not pose a risk for reduced weight, we found no evidence for the beneficial effect of slow refeeding in patients with acute AN.

Purpose Adrenal incidentaloma (AI) and adrenal masses in cases of subclinical Cushing’s syndrome (SCS) initially require follow-up imaging. In this study we used endoscopic ultrasound (EUS) as a method for high-resolution imaging. The aim was to evaluate the growth rate of AI and SCS by EUS. Materials and Methods This retrospective analysis included 93 out of 229 patients with AI or SCS who were investigated longitudinally by EUS in our university hospital between 1997 and 2013. The longitudinal follow-up required at least two investigations by EUS and evaluation of endocrine function. Plasma renin, serum aldosterone, 24 h urinary catecholamines and 2 mg dexamethasone suppression test were performed. EUS was performed at baseline and during follow-up. Each time, the maximum diameter was measured. Three groups were defined: non-functioning adenomas (NFA), non-functioning nodular hyperplasias (NFH) and SCS. Results 86 patients had non-functioning masses [NFM] (59 NFA, 48 NFH) and 7 patients had SCS (10 masses). At baseline the mean diameter was 19.4 (± 9.3) mm (NFM) and 19.6 (± 9.2) mm (SCS). The mean follow-up period was 31.6 ± 28.7 months. The estimated mean growth rates per year were low: They were 0.35 mm/yr [NFA], 0.02 mm/yr [NFH] and 0.53 mm/yr [SCS]. Furthermore, there was no malignant progression of any mass. Conclusion The growth rate as determined by EUS was low for all tumor entities observed in this study. There was no difference in tumor growth between the groups.

Background:Rheumatoid arthritis (RA) is a chronic inflammatory joint disease potentially leading to disability, impaired functioning, and premature death. Most treatment strategies include the early use of disease-modifying antirheumatic drugs (DMARDs) such as methotrexate (MTX) which is considered as an established ‘anchor’ therapy. Since it takes some weeks until MTX shows clinical efficacy, glucocorticoids (GC) are widely used for bridging.Objectives:The aim of the study “Comparison of the efficacy and safety of two starting dosages of prednisolone in early active RA” (CORRA) is to compare the efficacy and safety of two standard GC bridging schedules vs. placebo in addition to MTX, following a treat-to-target regimen, in early RA.Methods:CORRA is an investigator-initiated, randomised, multi-center, double-blind, placebo-controlled trial. Adult RA patients who were eligible for inclusion in the trial if they had a disease duration of less than 3 years and moderate or high disease activity were recruited in one hospital and 18 rheumatology practices in Germany. Patients were randomised (1:1:1) to receive 60 mg or 10 mg prednisolone (Pred) orally once daily (tapered down to 5 mg Pred within 8 weeks) or placebo. The duration of the intervention was 12 weeks, followed by an open observational phase for another 40 weeks. All patients were also treated with MTX (usually starting with 15mg/week followed by a treat-to target scheme). The primary efficacy endpoint was the progression of the radiographic joint damage after one year compared to baseline as determined by the van der Heijde modification of the Sharp score (SHS). Patients, physicians and readers of radiographs were unaware of the treatment assignments. For the comparison of the two GC groups, a non-inferiority margin of 1.3 points of the SHS was set. This trial was registered at ClinicalTrials.gov, numberNCT02000336.Results:Between February 2014 and February 2017, 395 patients were included in the trial, 381 of which had sufficient data also of follow-up visits. A total of 129 patients were assigned to the 60 mg Pred group, 124 to 10 mg Pred and 128 to the placebo group. At baseline, mean age was 58 years, 58% were female, 55% were rheumatoid factor and 52% ACPA positive. The mean number of swollen joints was 12.8 out of 28, mean ESR was 33.6 mm/h, mean CRP 2.2 mg/dL, mean DAS 28 6.0. Radiographic damage was 4.9 as measured by the SHS. In the 60 mg, 10 mg Pred group and in the placebo group, the DAS 28 was 2.6, 3.1, 4.5 at week 4 (pConclusion:The bridging schedule starting with 60 mg Pred reduced disease activity better than the 10 mg schedule or placebo only for a short time. The primary outcome structural damage was non-inferior in the 10 mg Pred and the placebo group in comparison to the 60 mg Pred group. Initial advantages of the higher dose may have been compromised by the long follow-up with the possible escalation of therapy due to the treat-to-target regimen.Disclosure of Interests:Dietmar Krause Grant/research support from: Pfizer and AbbVie (Abbott), Anna Mai: None declared, Nina Timmesfeld: None declared, Ulrike Trampisch: None declared, Renate Klaassen-Mielke: None declared, Henrik Rudolf: None declared, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Elmar Schmitz: None declared, Claas Fendler: None declared, Claudia Klink: None declared, Stephanie Boeddeker: None declared, Ertan Saracbasi: None declared, Jochen Christoph: None declared, Manfred Igelmann: None declared, Hans Juergen Menne: None declared, Albert Schmid: None declared, Hans J Trampisch: None declared, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

Background: Allergen extract-based versus (vs.) molecular allergen component-based sIgE determination assays vary in their diagnostic performance. Methods: The Euroline® (EL) (Euroimmun) immunoblot (37 extracts and components), the ImmunoCAP ISAC 112® (ISAC) (ThermoFisher Scientific, TFS) microarray (112 components) and the ImmunoCAP® (CAP) (TFS) sx1 (8 extracts) and fx5 (6 extracts) panels were tested among 97 children (69 asthmatic and 28 healthy). Results: Prevalence of allergen sensitization (threshold ≥ 0,7 kU/l) was higher based on the CAP assay for all allergens tested except for peanut (more positive cases detected by ISAC) and soy (equal number of positive cases detected by ISAC). Lowest detection rates were associated with EL for all allergens compared. Overall (and HDM) allergen sensitization concordance vs. the CAP demonstrated higher sensitivity of the ISAC and comparable specificity between ISAC and EL. Quantitative (including CAP class) concordance between CAP and EL depicted a higher analytical sensitivity for CAP but also discrepant results (eg high HDM sIgE with CAP and negative with EL). For both aero-and food-allergens there were samples which were positive for a molecular component although negative for the respective extract. Such cases were more abundant when the comparison was vs. EL as compared to CAP. Conclusions: We observed discrepancies in detection rates of allergen sensitization between the applied methods. Such differences are important for atopy screening and monitoring especially in large epidemiological studies.

BACKGROUND The internet has become one of the most important sources to obtain medical and health information. Parents, whose children are affected by systemic diseases, anomalies, deformities or further orthopaedic defective positions, use the internet to increase their knowledge. OBJECTIVE There is a lack of studies with focus of parental enquiries in the internet before contacting the pediatric orthopaedic surgeon. This study shows current trends and also allows a follow up. METHODS Parental internet search was evaluated using a standardized questionnaire. General habits of internet use, local hardware equipment, age and educational background of the parents were analyzed. In particular, parental use of general medical websites, use of search machines like Google or Yahoo or the use of homepages from support groups was asked. RESULTS A total of 521 questionnaires were completed, this corresponds to a response rate of 96%. One quarter of parents attended the consultation because of a gait anomaly or foot deformity, followed by children with DDH (20%), club foot (9%) and scoliosis (6%). 87% of parents use a Smartphone to get internet access, 68% a Laptop, 55% a Tablet and 45% a Laptop. Especially parents with children with clubfoot looked for health information online (80%), followed by scoliosis 69% (n=20), DDH 67% (n=66), foot deformity / gait anomaly 49% (n= 62). 98% of those using the internet for health medical purpose made use of a search engine, 99% (n=291) of internet users searched through Google, with 44% (n=129) of them describing their research helpful. Concerning use of social media responders of clubfoot children were again the most numerous in number (38%, n=18). 10 of them stated to have exchanged with other social media users and 60% of them evaluated social media as helpful. There were 35 parents who intended to discuss the results with their pediatric orthopedic surgeon. 84% of the responders who used the internet for health research would return to the internet. CONCLUSIONS This study documents that the internet is an important source of information for parents or caregivers in the field of pediatric orthopedics and that the meaning goes even further. Treating physicians will increasingly be confronted with the results of internet research. In particular, parents whose children suffer from club feet frequently research the Internet. CLINICALTRIAL The study was conducted in accordance with the principles laid down in the Declaration of Helsinki. Prior to the investigations, an approval was secured by the local board of ethics on 8 of September 2017 (AZ 107/17).

Background/aim The extent of neck dissection in patients with head and neck cancer (HNSCC) and N0 neck remains controversial. The aim of this study was to evaluate the influence of lymph node yield on overall survival in patients with pathologically node-negative HNSCC. Patients and methods A retrospective analysis was performed on 157 pN0 HNSCC patients undergoing primary surgery with neck dissection between 2000 and 2014. The patients were divided into three groups according to the lymph node count using the optimal cut-points method. The Kaplan-Meier method and log-rank test were used to analyze overall survival and compare survival curves. Results The lymph node count cut-offs were determined to be 15 and 40. A total of 22 patients had 1-14, 79 patients had 15-39 and 56 patients had 40 or more harvested lymph nodes. There were significant differences in survival between all groups (p=0.001). Conclusion A lymph node yield of at least 15 nodes was significantly associated with better overall survival in pathologically node-negative patients who underwent surgical resection of HNSCC.