Decreasing sunbed use in the German population between 2001 and 2015: survey in 155 679 working persons.

BACKGROUND: UV radiation is a proven cause of skin cancer. Use of sunbeds has been shown to provide an attributable risk. OBJECTIVE: To evaluate the proportion of regular sunbed use in Germany based on large-scale population-based surveys over 15 years. METHODS: Skin cancer screenings by dermatologists were conducted between 2001 and 2015 in more than 500 German companies, including a clinical examination and interviews on the risk behaviour related to sunburns and sunbeds. RESULTS: Among 155 679 persons included regular sunbed use significantly declined from 11.0% in 2001 to 1.6% in 2015 (P < 0.001). There were significantly higher rates of sunbed use in women (12.5%/2.0%) vs. men (7.3%/1.3%; P < 0.001), in younger persons and in participants with darker skin (type II and III) vs. fair skin (type I). Individuals with sunburns in childhood were significantly more often sunbed users (5.1% vs. 4.6%; P = 0.002). A remarkable decline of sunbed use was observed after 2009 (7.0% in 2001-2008 and 2.2% in 2009-2015). This reduction occurred in the time of a legal ban of sunbed use for minors but also with the start of the national skin cancer screening programme. CONCLUSION: Use of sunbeds in the German adult population has dropped by more than 85% in the past decade. Primary prevention, including the large public awareness following the legal ban of sunbed use for young people and the effects of the statutory skin cancer screening programme may have contributed to this.

Perception and image of dermatology in the German general population 2002-2014.

BACKGROUND: In contrast to other European countries, dermatologists in Germany provide health care for a broad spectrum of diseases of the skin and mucous membranes. Current population-based data on the perception of dermatology were lacking to date. OBJECTIVE: Analysis of the perception of dermatology from the general population's perspective with regard to utilization, satisfaction and responsibility. METHODS: Nation-wide survey on awareness, utilization, rating and image of dermatology in October 2014 through computer-assisted telephone interviews on a representative sample of the adult general population (n = 1015), performed by the FORSA institute. RESULTS: Dermatologists as a medical specialist group are familiar to 88% of the population (2002: 65%), and approx. 82% of respondents underwent dermatological treatment in the past. Satisfaction with this treatment is high to very high in 80-90% of respondents. The majority (60-80%) name dermatologists as the desired primary provider of care for the largest share of common skin diseases. For allergic diseases, mucous membrane diseases, venous disorders and paediatric skin diseases, this rate is significantly below 50%. CONCLUSIONS: In Germany, dermatologists are perceived and valued as providers of care. In the case of skin cancer and chronic inflammatory skin diseases, they are experienced as primary care givers, whereas they are associated less frequently than their competence would justify with providing treatment for allergic and mucous membrane diseases and venous disorders. Further education of the general public and medical profession is required.

[Perception of statutory skin cancer screening in the general population : Current findings on participation, knowledge and evaluation]. / Die Wahrnehmung des gesetzlichen Hautkrebsscreenings in der Allgemeinbevölkerung : Aktuelle Erkenntnisse über Teilnahmequote, Kenntnisstand und Beurteilung.

BACKGROUND: Since 2008, German statutory health insurances offer routine skin cancer screening (rSCS) as a standard benefit. Insured persons aged 35 years and older are eligible for screening every 2 years. OBJECTIVES: The aim of the study was to evaluate perception and utilization of rSCS in the general population. MATERIALS AND METHODS: A representative random sample of n = 1004 adult members of the German statutory health insurances were surveyed by the Forsa Institute via computer-assisted telephone interviews in a cross-sectional study in April 2015. RESULTS: On 39% of all persons interviewed, skin cancer screening had been executed at least once; the percentage of those entitled for rSCS was 45%. Of the participants, 50% were aware of the rSCS eligibility framework, with multiple sources of information. In 82% of cases, rSCS was performed by a dermatologist. The majority (87%) of those who had already undergone rSCS stated that the advantages of the procedure outweighed inconveniences. While participation in rSCS constantly increased (2011-2013-2015), knowledge of eligibility did not. CONCLUSIONS: Seven years after implementation, rSCS has been utilized by almost half of those entitled and was rated positively by the majority. However, lack of knowledge about rSCS eligibility is also present in 50%. Further targeted informative measures are needed to increase awareness of rSCS.

[Risk characteristics and survival rates of malignant melanoma in Germany and the Netherlands]. / Risikomerkmale und Überlebensrate des malignen Melanoms in Deutschland und den Niederlanden.

BACKGROUND: Mortality and lethality of malignant melanoma (MM) show marked variations throughout Europe, thereunder a higher risk within the Netherlands (NL) when compared to Germany (D). GOAL AND METHODS: Comparison of systems and exploration of possible causal factors that could explain the difference between D and NL. Comparative healthcare research analysis using published international literature, as well as publicly accessible databases, and a subsequent hypothesis-generating analysis. RESULTS: The higher rate of excised MM less than 1 mm in diameter in D (65 % vs. 45 %) confirms the clinical reports of the cancer registries. The biological factors for the emergence of MM, such as skin type, do not seem to significantly differ from each other. Among the further potential predictors there are no relevant differences within, for example, geographical conditions and the qualifications of the treating physicians. Primary prevention has a longer continual tradition in D. Here, secondary prevention is characterized by population-based extensive screening, which does not occur within the NL. In addition, distinct differences are found regarding access to dermatologists. CONCLUSION: System access to a medical specialist and the prevention of skin cancer are currently the most distinctive potential determinants of more favorable MM survival rate in Germany.

[Regional differences in the health care of basal cell carcinoma]. / Regionale Unterschiede in der Versorgung des Basalzellkarzinoms.

BACKGROUND: Basal cell carcinoma (BCC) is the most common type of skin cancer in Germany. So far, it is unclear whether regional variations exist in the health care of the BCC. OBJECTIVES: Analysis of regional variations in health care (e. g., skin cancer screening) and their causes using the example of BCC. MATERIALS AND METHODS: Qualitative and quantitative analysis of the regional health care situation of BCC based on three studies was undertaken. These studies include the analysis of n = 7015 histopathological indications whose average tumor thickness is regarded as a characteristic of the quality of care, and a secondary data analysis of GK insured (n = 6.1 million DAK-insured persons), and a nationwide survey (FORSA) of n = 1004 participants focusing on the use of skin cancer screening. RESULTS: Analysis of the histopathological examination showed regional variations in average tumor depth of penetration. These are associated with the rural/urban characteristics of the region and individual sociodemographic indicators (e. g., employment sector or education). The results for age- and gender-specific use (DAK data) showed higher participation rates regarding skin cancer screening in western than in eastern federal states (Bundesländer). Moreover, it was revealed that the trend for using skin cancer screening was higher in urban than in rural areas. The results of population-related surveys confirm this trend. CONCLUSION: Although it is not possible to compare the studies directly, all three showed an association between city/state and the use of skin cancer screenings. In addition, sociodemographic characteristics that are related to the quality of health care were identified.

[Primary cutaneous cryptococcosis : Pigeons can carry more than letters !] / Primär kutane Kryptokokkose : Tauben können mehr als Briefe transportieren !

In the event of non-specific epidermal lesions, the importance of a comprehensive anamnesis becomes especially apparent. In the following, we report on a patient case in which only a focused anamnesis was able to bring light into the darkness of numerous differential diagnoses - and to produce the diagnosis of a rare but in this collective common illness: primary cutaneous cryptococcosis.

[Care for skin cancer in Germany : Provision and providers]. / Versorgung des Hautkrebses in Deutschland : Leistungsvolumina und -erbringer.

BACKGROUND: Treatment for skin cancer is a major component of dermatological care in western countries. OBJECTIVE: The purpose of this work is to analyze health care provision and providers for skin cancer care in Germany. METHODS: From the complete claims data set from 2007-2009 of the German statutory health insurance DAK (approximately 6.1 million insured persons), insurees with skin cancer and melanocytic naevi were extracted by ICD-10 codes. Surgical procedures and physician specialties were identified by specific codes. Data from the German statistical agency (Destatis) were derived from public domain for the years 2008-2010. RESULTS: Among the annual ambulatory surgical treatments (n = 6695) for melanoma, 83.6 % were conducted by dermatologists, followed by general surgeons (11.1 %), and facial surgeons (3.0 %). In melanocytic naevi (n = 51,659), 79.1 % were treated by dermatologists, followed by general surgeons (15.5 %), facial surgeons (3.6 %), and general practitioners (1.1 %), while in epithelial cancers (ICD-10 C44), 76.4 % were operated by dermatologists, followed by general surgeons (12.7 %) and facial surgeons (7.9 %). Overall, related to Germany, about 830,000 ambulatory operations for skin cancer were conducted in 2009 which is about 40 % more than in 2007. In hospitalized patients, 79,448 out of 195,558 inpatient cases (45.5 %) were treated in dermatological departments in the year 2012. Average annual growth rates of the inpatient cases in the DAK between 2007 and 2010 were 8.9 % for MM and 11.1 % for SCC/BCC. CONCLUSION: Skin cancer is associated with a significant and still growing need for surgical care in which dermatology has a leading role in Germany. Thus, there is an increasing need for dermato-surgical specialist training.

The German National Program on Psoriasis Health Care 2005-2015: results and experiences.

In 2005, the first national psoriasis survey in Germany revealed large deficits in health care particularly in patients with moderate to severe disease. The consecutive goal was to improve health care for psoriasis countrywide. For this, a large-scale national program was initiated starting with a comprehensive analysis of structures and processes of care for psoriasis. Patient burden, economic impact and barriers to care were systematically analyzed. In order to optimize routine care, a S3 guideline, a set of outcomes measures and treatment goals, were developed. Implementation was enforced by the German Psoriasis Networks (PsoNet) connecting the most dedicated dermatologists. The annual National Conference on Health Care in Psoriasis established in 2009 consented National Health Care Goals in Psoriasis 2010-2015 and defined a set of quality indicators, which are monitored on a regular basis. Currently 28 regional networks including more than 800 dermatologists are active. Between 2005 and 2014 7 out of 8 quality indicators have markedly improved, and regional disparities were resolved. e.g., mean PASI (Psoriasis Area Severity Index) dropped from 11.4 to 8.1 and DLQI (Dermatology Life Quality Index) from 8.6 to 5.9. A decade of experience indicates that a coordinated nationwide psoriasis program based on goal orientation can contribute to better quality of care and optimized outcomes.

Participation and health care provision of statutory skin cancer screening in Germany - a secondary data analysis.

BACKGROUND: In Germany, skin cancer screening was introduced nationwide in July 2008. From the age of 35 years, members of the statutory health insurance are eligible for screening every 2 years. OBJECTIVE: The aim of this study is to calculate the participation rates and the proportions of health care providers of statutory skin cancer screening in Germany on a population-based level. METHODS: Data were provided by a nationwide German statutory health insurance, approximately 6.1 million members, covering the years 2008/2009. Participation rates were calculated per yearly quarter and were adjusted for age, gender and federal state. RESULTS: Approximately 920,000 insurants were screened from the third quarter of 2008 until the last quarter of 2009. Mean participation rate of skin cancer screening was 30.8%. Women had higher participation rates (31.9%) than men (29.7%). After adjusting for gender and federal state, high rates for pensioners at the age of 65-74 were confirmed at 39.4% on average for all yearly quarters. One of the highest gender- and age-adjusted rates was observed in the state of Schleswig-Holstein, where a population based pilot project had been implemented before the start of the nationwide screening programme. In general, without taking into account Berlin, former East Germany had a much lower gender- and age-adjusted participation rate (23.9%) than West Germany (33.3%). At the first quarter after implementation of screening, 58.5% of the screenings were provided by dermatologists and 41.5% by general practitioners. CONCLUSION: Participation rates and health care providers of skin cancer screening can be calculated from secondary data and contribute to identify group- and region-specific participation patterns in order to improve early detection of skin cancer.

Prevalence and risk factors of actinic keratoses in Germany--analysis of multisource data.

BACKGROUND: In Europe, only few and inconsistent data on the prevalence and treatment of actinic keratoses (AK) are available. OBJECTIVES: To determine the prevalence of AK in Germany, to identify potential predictors and to estimate the number of AK cases treated in dermatological practices. METHODS: In a multiple-source approach, prevalence was assessed from whole-body examinations in a cohort of 90 800 employees and from nationwide statutory health insurance (SHI) data of 2008. The number of cases documented in dermatological offices was estimated from statistics of a SHI Physicians Association. RESULTS: Standardized prevalence of AK from dermatological examinations was 2.7%; the rate increased with age (11.5% in the group 60-70 years) and was higher for men (3.9%) than for women (1.5%). Significant associations were also identified for skin phototype I, sunburns in childhood and solar lentigines. Vitiligo and a history of melanoma were also, but not significantly, associated with AK. In the SHI data analysis, standardized AK prevalence was 1.8%. Age-specific rates were below 1.5% up to 60 years and rose to 8.2% (13.2% in men) in the group 80-89 years. The prevalence from these large data sets--which is at the lower limit of studies from other countries--suggests about 1.7 million estimated AK cases in Germany. In 2011, AK accounted for 8.3% of the hundred most frequently treated dermatological outpatient diagnoses. The proportion of AK cases has risen almost continuously over the last 10 years, compared to other dermatological conditions. Estimated annual number of AK cases documented by dermatologists in Germany is about 1.7 million. CONCLUSIONS: Actinic keratosis is a frequent condition in higher age groups and more prevalent in men; a relevant need for health care is evident. Predictors and risk factors for AK are easy to identify in the population, which could also help to detect groups with special need for preventive measures.

The Euromelanoma skin cancer prevention campaign in Europe: characteristics and results of 2009 and 2010.

BACKGROUND: Euromelanoma is a skin cancer education and prevention campaign that started in 1999 in Belgium as 'Melanoma day'. Since 2000, it is active in a large and growing number of European countries under the name Euromelanoma. OBJECTIVE: To evaluate results of Euromelanoma in 2009 and 2010 in 20 countries, describing characteristics of screenees, rates of clinically suspicious lesions for skin cancer and detection rates of melanomas. METHODS: Euromelanoma questionnaires were used by 20 countries providing their data in a standardized database (Belgium, Croatia, Cyprus, Czech Republic, FYRO Macedonia, Germany, Greece, Hungary, Italy, Lithuania, Luxembourg, Malta, Moldavia, Portugal, Serbia, Slovenia, Spain, Sweden, Switzerland and Ukraine). RESULTS: In total, 59,858 subjects were screened in 20 countries. Most screenees were female (64%), median ages were 43 (female) and 46 (male) and 33% had phototype I or II. The suspicion rates ranged from 1.1% to 19.4% for melanoma (average 2.8%), from 0.0% to 10.7% for basal cell carcinoma (average 3.1%) and from 0.0% to 1.8% for squamous cell carcinoma (average 0.4%). The overall positive predictive value of countries where (estimation of) positive predictive value could be determined was 13.0%, melanoma detection rates varied from 0.1% to 1.9%. Dermoscopy was used in 78% of examinations with clinically suspected melanoma; full body skin examination was performed in 72% of the screenees. CONCLUSION: Although the population screened during Euromelanoma was relatively young, high rates of clinically suspected melanoma were found. The efficacy of Euromelanoma could be improved by targeting high-risk populations and by better use of dermoscopy and full body skin examination.

A new instrument for the assessment of patient-defined benefit in the treatment of allergic rhinitis.

BACKGROUND: Allergic rhinitis (AR) is a common disease that affects health-related quality of life (HRQoL). Current and future health policy demands the assessment of patient-relevant treatment benefit for evaluation of treatments. METHODS: We developed, validated and tested a standardized instrument for the assessment of patient-relevant needs and benefits in AR. In an open survey of patients with AR, 100 need and benefit items were generated. The items were condensed to a 25-item list by an expert panel. On this list, patient rates the personal importance of 25 treatment needs on a scale ranging from 'not at all' to 'very' before treatment (Patient Needs Questionnaire, PNQ). At the end of the treatment, patient rates the extent, to which these needs were achieved by treatment from 'did not help at all' to 'helped a lot' (Patient Benefit Questionnaire). The patient benefit index (PBI) is computed to provide a global weighted benefit parameter. This disease-specific instrument was validated in n = 104 patients with AR. RESULTS: The PBI-AR showed good acceptability and feasibility in clinical routine. Reduction in nose and eye symptoms was rated most important. The PBI amounted to 2.2 (PBI ranges from 0 = 'no benefit' to 4 = 'maximum benefit'). Reliability of the PNQ was high (Cronbach's alpha = 0.9).The PBI was significantly correlated with relevant external validation criteria, such as patient satisfaction (R = 0.54) and HRQoL (R = 0.26). CONCLUSION: The PBI-AR is a feasible, reliable and valid instrument for the standardized assessment of patient-relevant benefits in the treatment of AR.

Esophageal manometry and 24-hour pH monitoring to evaluate laparoscopic Lind fundoplication in gastroesophageal reflux disease.

Laparoscopic and thoracoscopic techniques have provided a new dimension in the correction of functional disorders of the esophagus. Therapeutic success, however, depends on the confirmation of esophageal disease as a cause of the symptoms, on understanding the basic cause of dysfunction and on identifying the surgical patient. This study is a retrospective study of patients submitted to surgery using the Lind procedure for gastroesophageal reflux disease (GERD). The purpose of this study is to establish the value of the routine use of esophageal manometry and 24-hour pH monitoring in order to select patients and perform pre and postoperative functional evaluation. Forty-one patients (68.3%) had a hypotonic lower esophageal sphincter. The average pressure was 9.2 mm Hg preoperatively and 15.2 mm Hg postoperatively, with an increase of 6.0 mm Hg. This increase was 8.8 mm Hg in hypotonics and 4.3 mm Hg in the normotonics. There was a certain degree of hypomotility of the esophageal body in 14 patients (23.3%) and, of this group, 4 (28.5%) improved postoperatively. Pathological acid reflux was found in 51 cases (85.0%) by pH monitoring. The mean of the preoperative DeMeester score was 31.4, later dropping to 3.2. Esophageal manometry and 24-hour pH monitoring are effective methods for revealing the level of functional modification established by anti-reflux surgery and for helping to objectively perform the selection.

Laparoscopic hernia repair--complications.

Laparoscopic hernioplasty is a technique which can present a number of specific complications. This paper reviews the complications that can occur during laparoscopic hernia repair and ways to avoid them; it also describes the surgical technique used successfully in over 1000 cases. Initial experience suggests that complications can be avoided with adequate knowledge, attention to surgical anatomy and the proper technique of laparoscopic hernioplasty. Early recurrences are rare and invariably result from inadequate surgical technique. Inadequate fixation of the mesh, inadequate mesh size, and failure to cover unidentified wall defects (hernias which have never been repaired), are the main causes of early recurrence of hernia. Experience, knowledge of complications and how to avoid them, adequate training and attention to the anatomy of the inguinal region are the most important factors in correcting inguinal hernia successfully by laparoscopy.

Intracellular chloride activity of leech neurones and glial cells in physiological, low chloride saline.

Leech blood apparently contains considerably less chloride than generally used in physiological experiments. Instead of 85-130 mM Cl- used in experimental salines, leech blood contains around 40 mM Cl- and up to 45 mM organic anions, in particular malate. We have reinvestigated the distribution of Cl- across the cell membrane of identified glial cells and neurones in the central nervous system of the leech Hirudo medicinalis L., using double-barrelled Cl(-)- and pH-selective microelectrodes, in a conventional leech saline, and in a saline with a low Cl- concentration (40 mM), containing 40 mM malate. The interference of anions other than Cl- to the response of the ion-selective microelectrodes was estimated in Cl(-)-free salines (Cl- replaced by malate and/or gluconate). The results show that the absolute intracellular Cl- activities (aCli) in glial cells and neurones, but not the electrochemical gradients of Cl- across the glial and the neuronal cell membranes, are altered in the low Cl-, malate-based saline. In Retzius neurones, aCli is lower than expected from electrochemical equilibrium, while in pressure neurones and in neuropil glial cells, aCli is distributed close to its equilibrium in both salines, respectively. The steady-state intracellular pH values in the glial cells and Retzius neurones are little affected (< or = 0.1 pH units) in the low Cl-, malate-based saline.