[Mortality among premature newborns below 32 weeks of gestational age depending on level of care and patient volume in Nordrhein-Westfalen/Germany]. / Mortalität bei Frühgeborenen < 32 Schwangerschaftswochen in Abhängigkeit von Versorgungsstufe und Patientenvolumen in Nordrhein-Westfalen.

BACKGROUND: It is an ongoing debate in Germany whether there is an association between the number of preterm infants admitted to a neonatal unit per year and neonatal mortality. Data from Germany on this topic are sparse and the generalizability of this data is questionable in face of a heterogeneous organization of perinatal care among federal states. METHODS: We used data from a state-wide quality assurance program in Nordrhein-Westfalen/Germany, encompassing 3 930 newborns below 32 completed weeks gestation p. m. admitted during the years 2004 and 2005. We hypothesized that there is an association between annually admitted premature infants below 32 completed weeks of gestation and mortality rates among these patients. RESULTS: Mortality below 28 completed weeks gestation was significantly lower in hospitals admitting more than 50 premature infants < 32 completed weeks gestation per year compared to smaller hospitals (odds ratio 0.55, 95 %-CI 0.41-0.74, p < 0.001). When lowering the critical threshold to hospitals admitting more than 40 premature infants < 32 weeks gestation, only in newborns < 25 completed weeks gestation a significant effect could be demonstrated. The level of care (level 1-3) was off less importance than patient volume. CONCLUSION: In Nordrhein-Westfalen/Germany, survival rate of immature infants is significantly higher if treated in larger neonatal intensive care units with a minimal annual volume of more than 40-50 premature infants < 32 weeks GA. Patient volume seemed to be a better indicator of performance than formal level of care.

[On the prognosis of hip fractures. Assessment of mortality after hip fractures by analyzing overlapping segments of longitudinal data]. / Zur Prognose der Schenkelhalsfraktur. Beurteilung der Mortalität nach Schenkelhalsfraktur durch sektorübergreifende Datenzusammenführung.

BACKGROUND: Data on the treatment of hip fractures in acute care settings have been collected in a report card system for quality assurance in Germany since the beginning of the 1990s. However, there are no data on the long-term outcome and long-term quality of care. MATERIAL AND METHOD: In a retrospective study, data on 1393 patients from 1999 were collected from different sources: from the department of quality assurance at the medical association of Westfalia-Lippe, the Statutory Health Insurance Funds (AOK), and the Medical Review Board of the Statutory Health Insurance Funds (Medizinischer Dienst der Krankenkasse, MDK). Statistical analyses were performed by the Center for Clinical Studies of the University of Düsseldorf. RESULTS: Uni- and multivariate analyses reveal the following prognostic parameters for survival after hip fracture: sex, age, nursing care dependency, living in a nursing home, risk stratification according to ASA, and postoperative complications. Timing of the operation had no affect on survival. CONCLUSIONS: Prognostic factors for the outcome after hip fracture can only be obtained by analyzing data from the hospital stay and the post-hospital setting as well. Chances of survival can be significantly improved by rehabilitative care.

[Differences in the extent of diagnostic procedures after acute stroke in patients treated in departments of neurology, internal medicine and geriatric medicine]. / Art und Umfang der Diagnostik bei der Akutbehandlung von Schlaganfallpatienten in neurologischen, internistischen und geriatrischen Abteilungen.

BACKGROUND AND PURPOSE: In Germany, data about variations in acute stroke treatment between different facilities are lacking. The aim of the present study was to compare the extent of diagnostic procedures for acute stroke between departments of neurology, internal medicine, and geriatric medicine. METHODS: Stroke patients admitted to hospitals cooperating within the Westphalian Stroke Register between January 1, 2000 and December 31, 2001 were analyzed. Forty-two hospitals participated in the study including 24 departments of neurology, 13 of internal medicine, and 5 of geriatric medicine. The register is based on a standardized data assessment including sociodemographic and clinical characteristics of the patient, in the acute phase, as well as diagnostic and treatment procedures, complications, and status at discharge. The performance of brain imaging, Doppler, and echocardiography was defined as diagnostic standard for diagnosis and etiological classification of ischemic stroke. RESULTS: A total of 12,232 stroke patients were included. Mean age was 72 years, 49 % were men. In general, diagnostic procedures were administered more often in neurological departments compared to departments of internal or geriatric medicine. In all participating hospitals, the application of diagnostic techniques was less frequent in older patients. The defined diagnostic standard was performed more often in those neurological departments providing acute stroke unit services compared to neurological departments without stroke unit services. CONCLUSION: Our study detected variations in the extent of diagnostic procedures in acute stroke between different medical disciplines. However, further studies are required to clarify whether a more frequent performance of diagnostic techniques yields relevant therapeutic consequences.

[Factors influencing duration of hospitalization after stroke in Germany]. / Einflussfaktoren auf die stationäre Liegezeit nach Schlaganfall in Deutschland.

BACKGROUND: In Germany up-to-date data within community settings about factors influencing length of stay in acute hospitals are lacking. We, therefore, identified predictors for length of stay in acute hospital after ischemic stroke in a pooled analysis of large German stroke registers. METHODS: Ischemic stroke patients admitted to hospitals cooperating within the German Stroke Registers Study Group (ADSR) between January 1, 2000 and December 31, 2000 were analysed. The influence of patients' demographic and clinical characteristics as well as the characteristics of the treating hospitals on length of stay were analysed by multivariate linear regression. RESULTS: Overall, 13 440 patients after ischemic stroke were included in the analyses. Their mean age was 70 years, 53 % were men. Median length of stay in acute hospitals was 12 days. In multivariate analyses younger age, an increasing number of co-morbidities, and an increasing number of neurological deficits were identified as predictors of prolonged stay in hospital. Patients were more likely to stay longer in an acute hospital if they were to be discharged to a rehabilitation unit or to a nursing home. Length of stay was independently decreased for patients treated in hospitals providing acute stroke unit services and for hospitals treating more than 250 stroke patients per year. CONCLUSION: In addition to patients' demographic and clinical characteristics, length of stay in hospital was influenced by the hospitals' characteristics. Especially the volume of treated patients and the organisation of services within the hospital may play the key role.

[Influence of institutional factors in neurological, medical and geriatric departments on length of stay in patients with stroke]. / Ausstattungsmerkmale von Krankenhäusern und ihr Einfluss auf die Liegezeit von Schlaganfallpatienten.

BACKGROUND: Length of hospital stay (LOS) is determined not only by medical procedures or complications but also by institutional factors. We examined the influence of various institutional factors in neurological, medical and geriatric departments on LOS in patients with ischemic stroke. METHODS: We used data of 12,410 patients from the Westphalian Stroke Register for the years 2000 and 2001. Forty-two centres including 24 neurological, 13 medical and five geriatric departments participated in the register. The register is based on a standardized data assessment, including patient-related sociodemographic and clinical items, diagnostic and treatment procedures, complications, and status at discharge. RESULTS: 7855 patients with ischemic stroke from 37 centres (median age: 73 years, 51 % female) were included in the analysis. In neurological departments, the LOS decreased with increasing numbers of stroke patients treated per centre and year, presence of a stroke unit or a rehabilitation unit. Conversely, the ratio beds to number of physicians was positively associated with LOS. In geriatric departments, a significant decrease in LOS with an increasing number of stroke cases and availability of a rehabilitation unit was also observed. In departments of medicine, no significant influence on LOS was found for the institutional factors analysed. CONCLUSIONS: Institutional factors have a significant influence on LOS in patients with stroke. In this analysis, the influence varied between the different medical specialties. Institutional factors gain importance in the management of stroke patients, when Diagnosis Related Groups (DRG) are introduced.

[Risk factors of retinopathy of prematurity in infants 32 to 36 weeks gestational age]. / Risikofaktoren für die Entstehung einer Frühgeborenenretinopathie bei einem Gestationsalter von 32 bis 36 Schwangerschaftswochen.

INTRODUCTION: In our study we determined possible risk factors for retinopathy of prematurity (ROP) in infants 32 to 36 completed weeks of gestational age based on a regional German neonatal database. We examined especially whether or not oxygen therapy over more than 3 days is related to a higher risk of ROP. MATERIALS: We identified 7172 ophthalmologically examined infants, 32 to 36 completed weeks gestational age, born from 1990 to 1996. ROP was diagnosed in 195 (2.7 %). We examined the following variables as risk factors for ROP in infants receiving oxygen for less than 4 days: gestational age, sex, blood pH of 7.0 or less, body temperature of 36 degrees C or less, phototherapy, blood pO2 of 35 mm Hg or less, small-for-gestational age, sepsis, ventilation after birth, and blood transfusion. RESULTS: Sex, blood pH of 7.0 or less, blood pO2 of 35 mm Hg or less, sepsis, phototherapy, and small-for-gestational age were not associated with a significant risk of ROP. A gestational age of 32 weeks compared to a gestational age of 36 weeks was associated with an increased risk of ROP (odds ratio, 2.95; 95 % confidence interval, 2.18 to 4.01). Ventilation after birth (adjusted OR, 2.29; 95 % CI, 1.70 to 3.15) and blood transfusion (adjusted OR, 5.28; 95 % CI, 3.80 to 7.23) increased the risk of ROP regardless of gestational age. Oxygen therapy for more than 3 days was not associated with an increased risk of ROP (OR, 1.06; 95 % CI, 0.67 to 1.70). CONCLUSION: In neonates delivered between 32 and 36 weeks of gestation, the duration of oxygen supplementation should not necessitate an ophthalmological examination. A vigorous restriction of blood transfusions could reduce the incidence of ROP.

[From "reporting" to "surveillance": documentation of abnormalities within the scope of perinatal data collection--a sensitive instrument for monitoring new technologies?]. / Vom "Reporting" zum "Surveillance": Die Fehlbildungsdokumentation im Rahmen der Perinatalerhebung--ein sensibles Instrumentarium zum Monitoring neuer Technologien?

Analysis of the Hamburg perinatal quality assurance programme shows a dramatic increase in congenital abnormalities of the bones, joints and muscles from 45.29 per 10,000 live births in 1990 to 106.32 in 1994. Comparisons with other perinatal quality assurance programme data reveal almost the same trend. In fact, there is no real increase in these specific congenital abnormalities, but there is an effect, which can be explained by the introduction of ultrasound hip screening in infancy signalling overdiagnostics due to the new technology. This example demonstrates that the perinatal quality assurance programme is a suitable instrument for registering congenital abnormalities and monitoring new technologies and interventions. These results support the proposal by the association of the leading state health officers (AGLMB) to use the already well-established quality assurance programmes which are analysed on state level for a systematic nation-wide documentation and "surveillance" of congenital abnormalities. In addition, it becomes clear that surveillance, understood as a further development of health reporting, offers an opportunity to effect both an assessment and a better orientation in respect of health policies.

[Left-sided flank pain in coincident infrarenal aortic aneurysm and left-sided nephropathy]. / Linksseitiger Flankenschmerz bei Koinzidenz eines infrarenalen Aortenaneurysmas und linksseitiger Nephropathie.

Two cases illustrating the difficult differential diagnosis of left-sided pain in the coincidence of nephropathy and aortic aneurysm are described. In both cases an aortic aneurysm was discovered, although the aneurysm caused the pain in the side in only one case. In particular, older men with recently occurring side or back pain must be examined with regard to aortic aneurysm. As the classic symptoms of a ruptured aneurysm are frequently disguised, aneurysm must always be considered as a cause of left-sided pain.

[Iatrogenic femoral pseudoaneurysm--an urgent surgical indication]. / Das iatrogene femorale Pseudoaneurysma--eine dringliche Operationsindikation.

Fifteen patients with an aneurysma spurium of the femoral artery due to coronary angiography had to be operated from March, 1988 till April, 1990. Contrary to our expectations we did not find a culmination of risk factors or relevant arteriosclerosis of the legs in these patients. It were the "young vessels" that were not able to compensate the defects from catheters and locks. In view of two cases of aneurysm rupture with hemorrhage, we consider the aneurysma spurium as an urgent indication for surgery. Only the complete exploration of the vessel permits an exact localization of the aneurysm and possible further defects and thus prevents the development of a secondary aneurysm.