A historical note about the sufficient cause model with special consideration of the work of Max Verworn 1912

PURPOSE

The aim of this paper is to present the historical roots of the sufficient component cause model, which is very well known in epidemiology.

METHODS

I have analyzed Max Verworn's writings on the description of the sufficient component cause model.

RESULTS

Verworn introduced a precursor of the sufficient component cause model as early as 1912, possibly inspired by Ernst Mach. He argued for the abandonment of the concept of "cause" (singular). Instead, he preferred the term "conditions." Unlike Karl Pearson, Verworn was not opposed to causal considerations. However, according to Verworn, every process or state is determined by numerous conditions and not by a single factor or "cause." Instead of speaking of causalism, Verworn preferred to speak of conditionalism.

CONCLUSIONS

The earliest description of the concept of the sufficient component cause model known in the epidemiological literature since 1976 dates back at least to 1912.

Adjuvant treatment and outcome of stage III melanoma patients: Results of a multicenter real-world German Dermatologic Cooperative Oncology Group (DeCOG) study

PURPOSE

Clinical trials demonstrated significantly improved recurrence-free survival (RFS) of melanoma patients receiving adjuvant treatment. As data from controlled trials are based on selected populations, we investigated adjuvantly treated stage III melanoma patients under real-world conditions.

PATIENTS AND METHODS

In a prior multicenter cohort study, stage III-IV melanoma patients were analysed for their choice of adjuvant therapy. In this follow-up study, we examined RFS, overall and melanoma-specific survival (MSS) and response to the subsequent treatment of 589 stage III patients (232 BRAF-mutated) receiving adjuvant PD-1 inhibitors (PD1; n = 479) or targeted therapy (TT; n = 110).

RESULTS

The median follow-up of the total cohort was 25.7 months. The main reason for premature discontinuation of adjuvant therapy was disease progression in PD1- (28.8%, n = 138/479) and adverse events in TT-treated patients (28.2%, n = 31/110). Among BRAF-mutated patients, RFS at 24 months was 49% (95% CI 40.6-59.0%) for PD1- and 67% (95% CI 58-77%) for TT-treated patients. The risk of recurrence was higher for BRAF-mutated PD1 than TT (hazard ratio 1.99; 95% CI 1.34-2.96; hazard ratio adjusted for age, sex and tumour stage, 2.21; 95% CI 1.48-3.30). Twenty-four months MSS was 87% (95% CI 81.0-94.1) for PD1 and 92% (95% CI 86.6-97.0) for TT. Response to subsequent systemic treatment for unresectable disease was 22% for all PD1- and 16% for TT-treated patients.

CONCLUSIONS

PD1-treated patients had more and earlier recurrences than TT patients. In BRAF-mutated patients, adjuvant TT might prevent early recurrences more effectively than PD1 treatment. Management of recurrence despite adjuvant treatment is challenging, with low response to current therapeutic options.

Population-Based Clinical Cancer Registration in Germany

INTRODUCTION

In 2013, a new federal law obligated all German federal states to collect additional clinical data in population-based cancer registries as an active tool for monitoring and improving the quality of cancer care, increasing transparency and promoting health research. Now, 10 years later, the current status of the expanded cancer registration is presented, including current figures on cancer in Germany.

METHODS

Reporting of cancer is mandatory for physicians, and about 5 to 10 reports from different healthcare providers are expected for each case. A uniform national dataset of about 130 items is used, and reports are usually sent electronically to the registry. We used the most recent data available from cancer registries up to the year of diagnosis in 2019. We calculated incidence rates and 5-year relative survival (5YRS) for common cancers. Data on clinical outcomes and benchmarking based on quality indicators (QIs) from guidelines were provided by the Cancer Registry Schleswig-Holstein (CR SH).

RESULTS

All federal state cancer registries met most of the previously defined national eligibility criteria. Approximately 505,000 cancer cases were registered in 2019, with breast, prostate, colorectal and lung cancer being the most common cancers. The age-standardised cancer incidence has slightly decreased during the last decade. and spatial heterogeneity can be observed within Germany. 5YRS for all cancers was 67% and 63% for women and men, respectively. Therapy data for rectal cancer in 2019-2021 from the CR SH are shown as an example: 69% of the registered patients underwent surgery, mostly with curative intent (84%) and tumour-free resection (91%). Radiotherapy was given to 33% of the patients, and chemotherapy was given to 40%. Three selected QIs showed differences between involved healthcare providers.

DISCUSSION

The implementation of population-based clinical cancer registration can be considered a success. Comprehensive recording of diagnosis, treatment and disease progression and the use of registry data for quality assurance, benchmarking and feedback have been implemented.

Outcome after intracranial hemorrhage under dabigatran and reversal with idarucizumab versus under vitamin-K-antagonists - the RIC-ICH study

BACKGROUND

Intracranial hemorrhage (ICH) is a rare but serious side effect associated with the use of oral anticoagulants, such as dabigatran. The specific reversal agent for dabigatran, idarucizumab, is available for the management of individuals with ICH. The aim of this study was to provide real-world evidence on patients with ICH and effective treatment with dabigatran and reversal with idarucizumab in clinical routine compared to those under effective treatment with vitamin-K-antagonist (VKA).

METHODS

Registration of Idarucizumab for Patients with IntraCranial Hemorrhage (RIC-ICH) is a non-interventional study conducted in 22 German stroke units that prospectively enrolled dabigatran patients treated with idarucizumab. Retrospective data from VKA patients served as reference population. Main objective was in-hospital mortality. Further objectives included change in bleeding volume, stroke severity, and functional status.

RESULT

In-hospital mortality was 26.7% in 15 dabigatran and 27.3% in 88 VKA patients (hazard ratio 1.00, 95% CI 0.29-2.60). In patients with bleeding volume > 60 ml, mortality was lower in the dabigatran group (N = 6, 33%) compared to the VKA group (N = 15, 67%; HR 0.24, 95% CI 0.04-0.96). No differences were observed in secondary endpoints between dabigatran and VKA patients.

CONCLUSION

These results, based on data from routine clinical practice, suggest that in-hospital mortality after idarucizumab treatment is comparable to that in patients pretreated with VKA. Due to the low precision of estimates, the results must be interpreted with caution.

Associations of Migration, Socioeconomic Position and Social Relations With Depressive Symptoms - Analyses of the German National Cohort Baseline Data

Objectives: We analyze whether the prevalence of depressive symptoms differs among various migrant and non-migrant populations in Germany and to what extent these differences can be attributed to socioeconomic position (SEP) and social relations. Methods: The German National Cohort health study (NAKO) is a prospective multicenter cohort study (N = 204,878). Migration background (assessed based on citizenship and country of birth of both participant and parents) was used as independent variable, age, sex, Social Network Index, the availability of emotional support, SEP (relative income position and educational status) and employment status were introduced as covariates and depressive symptoms (PHQ-9) as dependent variable in logistic regression models. Results: Increased odds ratios of depressive symptoms were found in all migrant subgroups compared to non-migrants and varied regarding regions of origins. Elevated odds ratios decreased when SEP and social relations were included. Attenuations varied across migrant subgroups. Conclusion: The gap in depressive symptoms can partly be attributed to SEP and social relations, with variations between migrant subgroups. The integration paradox is likely to contribute to the explanation of the results. Future studies need to consider heterogeneity among migrant subgroups whenever possible.

Conventional Imaging, MRI and 18F-FDG PET/MRI for N and M Staging in Patients with Newly Diagnosed Breast Cancer

Background: This study compares the diagnostic potential of conventional staging (computed tomography (CT), axillary sonography and bone scintigraphy), whole-body magnetic resonance imaging (MRI) and whole-body ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET/)MRI for N and M staging in newly diagnosed breast cancer. Methods: A total of 208 patients with newly diagnosed breast cancer were prospectively included in this study and underwent contrast-enhanced thoracoabdominal CT, bone scintigraphy and axillary sonography as well as contrast-enhanced whole-body ¹⁸F-FDG PET/MRI. The datasets were analyzed with respect to lesion localization and characterization. Histopathology and follow-up imaging served as the reference standard. A McNemar test was used to compare the diagnostic performance of conventional staging, MRI and ¹⁸F-FDG PET/MRI and a Wilcoxon test was used to compare differences in true positive findings for nodal staging. Results: Conventional staging determined the N stage with a sensitivity of 80.9%, a specificity of 99.2%, a PPV (positive predictive value) of 98.6% and a NPV (negative predictive value) of 87.4%. The corresponding results for MRI were 79.6%, 100%, 100% and 87.0%, and were 86.5%, 94.1%, 91.7% and 90.3% for ¹⁸F-FDG PET/MRI. ¹⁸F-FDG PET/MRI was significantly more sensitive in determining malignant lymph nodes than conventional imaging and MRI (p < 0.0001 and p = 0.0005). Furthermore, ¹⁸F-FDG PET/MRI accurately estimated the clinical lymph node stage in significantly more cases than conventional imaging and MRI (each p < 0.05). Sensitivity, specificity, PPV and NPV for the M stage in conventional staging were 83.3%, 98.5%, 76.9% and 98.9%, respectively. The corresponding results for both MRI and ¹⁸F-FDG PET/MRI were 100.0%, 98.5%, 80.0% and 100.0%. No significant differences between the imaging modalities were seen for the staging of distant metastases. Conclusions:¹⁸F-FDG PET/MRI detects lymph node metastases in significantly more patients and estimates clinical lymph node stage more accurately than conventional imaging and MRI. No significant differences were found between imaging modalities with respect to the detection of distant metastases.

Accuracy of a Smartphone-Based Artificial Intelligence Application for Classification of Melanomas, Melanocytic Nevi, and Seborrheic Keratoses

Current artificial intelligence algorithms can classify melanomas at a level equivalent to that of experienced dermatologists. The objective of this study was to assess the accuracy of a smartphone-based "You Only Look Once" neural network model for the classification of melanomas, melanocytic nevi, and seborrheic keratoses. The algorithm was trained using 59,090 dermatoscopic images. Testing was performed on histologically confirmed lesions: 32 melanomas, 35 melanocytic nevi, and 33 seborrheic keratoses. The results of the algorithm's decisions were compared with those of two skilled dermatologists and five beginners in dermatoscopy. The algorithm's sensitivity and specificity for melanomas were 0.88 (0.71-0.96) and 0.87 (0.76-0.94), respectively. The algorithm surpassed the beginner dermatologists, who achieved a sensitivity of 0.83 (0.77-0.87). For melanocytic nevi, the algorithm outclassed each group of dermatologists, attaining a sensitivity of 0.77 (0.60-0.90). The algorithm's sensitivity for seborrheic keratoses was 0.52 (0.34-0.69). The smartphone-based "You Only Look Once" neural network model achieved a high sensitivity and specificity in the classification of melanomas and melanocytic nevi with an accuracy similar to that of skilled dermatologists. However, a bigger dataset is required in order to increase the algorithm's sensitivity for seborrheic keratoses.

No evidence for seasonal variations of the incidence of testicular germ cell tumours in Germany

The pathogenesis of testicular germ cell tumours (GCTs) is still incompletely understood. Any progress in its understanding must derive from observational studies. Recently, it has been suggested that the incidence of GCTs may follow a seasonal pattern based on circannual changes in the Vitamin D serum levels, with maximum incidence rates in winter months. To examine this promising hypothesis, we studied monthly incidence rates of testicular GCTs in Germany by analysing 30,988 GCT cases aged 15-69 years, diagnosed during 2009-2019. Monthly incident case numbers with data regarding histology and patient age were obtained from the Robert Koch Institut, Berlin, along with annual male population counts. We used precision weighting for deriving pooled monthly incidence rates for GCTs of the period 2009-2019. We stratified pooled rates by histology (seminoma and nonseminoma) and age (15-39 and 40-69 years). By assuming a cyclical effect, we used an estimator of the intensity of seasonal occurrence and report seasonal relative risks (RR). The mean monthly incidence rate was 11.93/105 person-months. The seasonal RR for testicular cancer over-all is 1.022 (95% CI 1.000-1.054). The highest seasonal RR was found in the subgroup of nonseminoma aged 15-39 years, with a RR 1.044 (95% CI 1.000-1.112). The comparison of the pooled monthly rates of the winter months (October-March) with the summer months (April-September) revealed a maximum relative difference of 5% (95% CI 1-10%) for nonseminoma, aged 15-39 years. We conclude that there is no evidence of a seasonal variation of incidence rates of testicular cancer. Our results are at odds with an Austrian study, but the present data appear sound because the results were obtained with precision weighted monthly incidence rates in a large population of GCT cases.

Impact of oral anticoagulation on inhospital mortality of patients with hip fracture - Analysis of nationwide hospitalization data

OBJECTIVES

Oral anticoagulation (OAC) may have an impact on mortality in cases hospitalized for hip fracture (HF). We studied nationwide time trends of OAC prescriptions and compared time trends of inhospital mortality of HF cases with and without OAC in Germany DESIGN: Retrospective cohort study SETTING: Nationwide German hospitalization, Diagnosis-Related Groups Statistic PATIENTS/PARTICIPANTS: All hospital admissions for HF 60 years and older in the years 2006 through 2020.

INTERVENTION

Additional diagnosis with a personal history of long-term use of anticoagulants (ICD code Z92.1).

MAIN OUTCOME MEASUREMENTS

Inhospital mortality RESULTS: Cases hospitalized for HF 60 years and older increased by 29.5%. In 2006, 5.6% had a documented history of long-term use of OACs. This proportion rose to 20.1% in 2020. Age-standardized hospitalization mortality in HF cases without long-term use of OACs in males decreased steadily from 8.6% (95% confidence intervals 8.2 - 8.9) in 2006 to 6.6% (6.3 - 6.9) in 2020 and in females from 5.2% (5.0 - 5.3) to 3.9% (3.7 - 4.0). Mortality of HF cases with long-term use of OACs remained unchanged: males 7.0% (5.7 - 8.2) in 2006 and 7.3% (6.7 - 7.8) in 2020, females 4.8% (4.1 - 5.4) and 5.0% (4.7 - 5.3).

CONCLUSION

Inhospital mortality of HF cases with and without long-term OAC show different trends. In HF cases without OAC, mortality decreased from 2006 to 2020. In cases with OAC such a decrease could not be observed.

The interplay of family history of depression and early trauma: associations with lifetime and current depression in the German national cohort (NAKO)

Introduction

Family history of depression and childhood maltreatment are established risk factors for depression. However, how these factors are interrelated and jointly influence depression risk is not well understood. The present study investigated (i) if childhood maltreatment is associated with a family history of depression (ii) if family history and childhood maltreatment are associated with increased lifetime and current depression, and whether both factors interact beyond their main effects, and (iii) if family history affects lifetime and current depression via childhood maltreatment.

Methods

Analyses were based on a subgroup of the first 100,000 participants of the German National Cohort (NAKO), with complete information (58,703 participants, mean age = 51.2 years, 53% female). Parental family history of depression was assessed via self-report, childhood maltreatment with the Childhood Trauma Screener (CTS), lifetime depression with self-reported physician's diagnosis and the Mini-International Neuropsychiatric Interview (MINI), and current depressive symptoms with the depression scale of the Patient Health Questionnaire (PHQ-9). Generalized linear models were used to test main and interaction effects. Mediation was tested using causal mediation analyses.

Results

Higher frequencies of the childhood maltreatment measures were found in subjects reporting a positive family history of depression. Family history and childhood maltreatment were independently associated with increased depression. No statistical interactions of family history and childhood maltreatment were found for the lifetime depression measures. For current depressive symptoms (PHQ-9 sum score), an interaction was found, with stronger associations of childhood maltreatment and depression in subjects with a positive family history. Childhood maltreatment was estimated to mediate 7%-12% of the effect of family history on depression, with higher mediated proportions in subjects whose parents had a depression onset below 40 years. Abuse showed stronger associations with family history and depression, and higher mediated proportions of family history effects on depression than neglect.

Discussion

The present study confirms the association of childhood maltreatment and family history with depression in a large population-based cohort. While analyses provide little evidence for the joint effects of both risk factors on depression beyond their individual effects, results are consistent with family history affecting depression via childhood maltreatment to a small extent.

Inverse association between apolipoprotein C-II and cardiovascular mortality: role of lipoprotein lipase activity modulation

AIMS

Apolipoprotein C-II (ApoC-II) is thought to activate lipoprotein lipase (LPL) and is therefore a possible target for treating hypertriglyceridemia. Its relationship with cardiovascular risk has not been investigated in large-scale epidemiologic studies, particularly allowing for apolipoprotein C-III (ApoC-III), an LPL antagonist. Furthermore, the exact mechanism of ApoC-II-mediated LPL activation is unclear.

METHODS AND RESULTS

ApoC-II was measured in 3141 LURIC participants of which 590 died from cardiovascular diseases during a median (inter-quartile range) follow-up of 9.9 (8.7-10.7) years. Apolipoprotein C-II-mediated activation of the glycosylphosphatidylinositol high-density lipoprotein binding protein 1 (GPIHBP1)-LPL complex was studied using enzymatic activity assays with fluorometric lipase and very low-density lipoprotein (VLDL) substrates. The mean ApoC-II concentration was 4.5 (2.4) mg/dL. The relationship of ApoC-II quintiles with cardiovascular mortality exhibited a trend toward an inverse J-shape, with the highest risk in the first (lowest) quintile and lowest risk in the middle quintile. Compared with the first quintile, all other quintiles were associated with decreased cardiovascular mortality after multivariate adjustments including ApoC-III as a covariate (all P < 0.05). In experiments using fluorometric substrate-based lipase assays, there was a bell-shaped relationship for the effect of ApoC-II on GPIHBP1-LPL activity when exogenous ApoC-II was added. In ApoC-II-containing VLDL substrate-based lipase assays, GPIHBP1-LPL enzymatic activity was almost completely blocked by a neutralizing anti-ApoC-II antibody.

CONCLUSION

The present epidemiologic data suggest that increasing low circulating ApoC-II levels may reduce cardiovascular risk. This conclusion is supported by the observation that optimal ApoC-II concentrations are required for maximal GPIHBP1-LPL enzymatic activity.

Estimates of excess mortality during the COVID-19 pandemic strongly depend on subjective methodological choices

Excess mortality is often used to assess the health impact of the COVID-19 pandemic. It involves comparing the number of deaths observed during the pandemic with the number of deaths that would counterfactually have been expected in the absence of the pandemic. However, published data on excess mortality often vary even for the same country. The reason for these discrepancies is that the estimation of excess mortality involves a number of subjective methodological choices. The aim of this paper was to summarize these subjective choices. In several publications, excess mortality was overestimated because population aging was not adjusted for. Another important reason for different estimates of excess mortality is the choice of different pre-pandemic reference periods that are used to estimate the expected number of deaths (e.g., only 2019 or 2015-2019). Other reasons for divergent results include different choices of index periods (e.g., 2020 or 2020-2021), different modeling to determine expected mortality rates (e.g., averaging mortality rates from previous years or using linear trends), the issue of accounting for irregular risk factors such as heat waves and seasonal influenza, and differences in the quality of the data used. We suggest that future studies present the results not only for a single set of analytic choices, but also for sets with different analytic choices, so that the dependence of the results on these choices becomes explicit.

On the gap between objective and perceived risks of COVID-19

A survey conducted by the German Socio-Economic Panel during the early phase of the SARS-CoV‑2 pandemic in spring 2020 showed that the perceived risks of SARS-CoV‑2 infection were a massive overestimation of the actual risks. A total of 5783 people (2.3% missing data) stated how likely they thought it was that SARS-CoV‑2 would cause a life-threatening illness in them in the next 12 months. The average subjective probability was 26%. We consider how such an overestimation could have occurred and how a more realistic risk assessment could be achieved in the population in a future pandemic. We show that qualitative attributes of the pandemic, the reporting of the media, and psychological features may have contributed to the overestimation of SARS-CoV‑2 risks. In its early stages, the SARS-CoV‑2 pandemic had qualitative characteristics known to lead to an overestimation of risks: The risks associated with the pandemic were new, unfamiliar, perceived as poorly controllable, and were taken involuntarily. Phenomena known from cognitive psychology such as the availability and anchor heuristics can also explain the overestimation of pandemic risks. Characteristics of media coverage such as the focus on individual fates and the associated neglect of the denominator also contributed to the gap between perceived and objective risk. In a potential future pandemic, people need to be vigilant but not in a panic. Better risk communication-for example, with better prepared figures and graphically presented percentages while avoiding the denominator neglect-could help the population to perceive risks of future pandemics more realistically.

The Epidemiology of Colorectal Cancer in Younger and Older Patients

BACKGROUND

Recent studies have shown that the incidence of colorectal cancer among younger persons is rising. We investigated incidence trends and survival in the German federal state of North Rhine-Westphalia.

METHODS

Cancer registry data from the period 2008-2019 were classified into two age groups (15-54 and 55-99). In each age group, the standardized incidence, average annual percent change (AAPC), and relative 5-year survival (RS) were calculated and stratified according to the site, histology, size, and grade of the colorectal tumor.

RESULTS

167 919 cases were included, with adenocarcinoma accounting for 86.4%. In 2019, the age-standardized incidence per 100 000 person-years was 13.8 and 10.3 among men and women (respectively) in the younger age group, compared with 197.9 and 126.3 in the older age group. Over the study period from 2008 to 2019, the incidence declined among older men and women (AAPC -2.6% and -2.9%) but remained nearly constant among younger men and women (- 0.5% and -0.4%). The incidence of neuroendocrine, T1, and G2 tumors rose in both age groups (AAPC range: 2.3%-12.2%; 2.2%-8.3%, 6.3%-8.8%). Younger patients have a better RS, with the largest difference between age groups being found for neuroendocrine tumors (88% and 83% in younger men and women, 65% and 61% in older men and women).

CONCLUSION

The incidence of colorectal tumors has remained constant in persons under age 55 and declined in persons aged 55 and older. Nonetheless, the incidence of neuroendocrine tumors and of small and well-differentiated tumors has risen in both age groups. The trends among younger persons and the rise in neuroendocrine tumors merit further study.

Time trends in survival and causes of death in multiple myeloma: a population-based study from Germany

BACKGROUND

Steady evolution of therapies has improved prognosis of patients with multiple myeloma (MM) over the past two decades. Yet, knowledge about survival trends and causes of death in MM might play a crucial role in long-term management of this patient collective. Here, we investigate time trends in myeloma-specific survival at the population level over two decades and analyse causes of death in times of prolonged survival.

METHODS

Age-standardised and age group-specific relative survival (RS) of MM patients aged < 80 years at diagnosis was estimated for consecutive time periods from 2000-2019 using data from the Cancer Registry of North Rhine-Westphalia in Germany. Conditional RS was estimated for patients who already survived one to five years post diagnosis. Causes of death in MM patients were analysed and compared to the general population using standardised mortality ratios (SMR).

RESULTS

Three thousand three hundred thirty-six MM cases were included in the time trend analysis. Over two decades, age-standardised 5-year RS increased from 37 to 62%. Age-specific survival improved from 41% in period 2000-2004 to 69% in period 2015-2019 in the age group 15-69 years, and from 23 to 47% in the age group 70-79 years. Conditional 5-year RS of patients who survived five years after diagnosis slightly improved as compared to unconditional 5-year RS at diagnosis. MM patients are two times more likely to die from non-myeloma malignancies (SMR = 1.97, 95% CI 1.81-2.15) and from cardiovascular diseases (SMR = 2.01, 95% CI 1.86-2.18) than the general population.

CONCLUSIONS

Prognosis of patients with MM has markedly improved since the year 2000 due to therapeutic advances. Nevertheless, late mortality remains a major concern. As survival improves, second primary malignancies and cardiovascular events deserve increased attention.

Natural History of Varicose Veins of the Legs

Objective To assess the natural history of saphenous and non-saphenous varicose veins using the results of the Bonn Vein Studies and data published in literature.

Methods We used the data of the Bonn Vein Studies (BVS) 1 and 2 to assess if preexisting non-saphenous varicose veins (NSVV) in persons who had no saphenous varicose veins (SVV) at baseline have an impact on the incidence of SVV during the follow-up of 6.6 years and vice versa. SVV where defined as tortuous or not-tortuous refluxing saphenous veins. The statistical evaluation was performed using SAS version 9.4 (SAS Institute, Cary, North Carolina). In addition, we performed a review of publications concerning the natural history of varicose veins (VV) using PubMed.

Results In the BVS the overall incidence of SVV within the follow-up time of 6.6 years was 8.0 % (n = 133 of 1661; 95 % CI: 6.8–9.4). 7.2 % (n = 107 of 1492) without VV in BVS 1 and 19.8 % (n = 26) of patients with preexisting NSVV developed SVV. The relative risk for the development of SVV in patients with preexisting NSVV was 2.44 (95% CI: 1.64–3.64) adjusted for age and sex. The overall incidence of NSVV was markedly higher with 13.3 % (n = 226 of 1661; 95 % CI: 11.8–15.1). During follow-up 148 patients (9.9 %) without VV in BVS 1 developed NSVV. 48.5 % (n = 78) of patients with preexisting SVV developed NSVV during follow-up. The relative risk for the development of NSVV in patients with preexisting SVV was 4.10 (95% CI: 3.26–5.16), adjusted for age and sex.

In published studies the development of VV is preceded by venous reflux. Initial VV may develop at any segment and the results from literature suggest that the location of VV and reflux at the time of the investigation depends on age. In younger individuals more distal location are reported with an ascending progression in the majority but also descending progression is possible.

Conclusions Based on the results of the Bonn Vein Studies 1 and 2 we could demonstrate, that preexisting SVV increase the risk of developing NSVV and preexisting NSVV increase the risk of developing SVV in a similar way. Venous reflux may initially occur in any segment of the venous system and may progress in antegrade and/or retrograde fashion. In younger adults initial VV seem to be localized more often in distal parts of the legs with an antegrade progression over time.

Temporal trends in referrals of RET gene carriers for neck surgery to a tertiary surgical center in the era of international management guidelines

PURPOSE

Thirty years into the genomic era, this study sought to explore events that helped transform the clinical landscape of hereditary medullary thyroid cancer (MTC).

METHOD

This retrospective analysis of prospectively collected data included all RET carriers referred to a tertiary center for neck surgery that was performed between 1986 and 2021, using descriptive statistics and Poisson regression analysis.

RESULTS

Altogether, 496 RET carriers were referred for thyroidectomy (388 carriers) or neck reoperation (108 carriers). Of these, 44 carriers had highest risk mutations (p.Met918Thr), 164 carriers high risk mutations (p.Cys634Arg/Gly/Phe/Ser/Trp/Tyr/insHisGluLeuCys), 116 carriers moderate-high risk mutations (p.Cys609/611/618/620/630Arg/Gly/Phe/Ser/Tyr) and 172 carriers low-moderate risk mutations (p.Glu768Asp, p.Leu790Phe, p.Val804Leu/Met, or p.Ser891Ala). Three event clusters drove referral numbers upward: a string of first reports of causative RET mutations between 1993 and 1998; the international consensus guidelines for diagnosis and therapy of MEN type 1 and type 2 in 2001; and the revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma in 2015. Referrals for neck reoperation declined sluggishly over 30 years, ending in 2018. Index patients continued to be referred into 2021. Referrals for thyroidectomy, grouped in 5-year increments, peaked in 1996-2000 for carriers of highest and high risk mutations, and in 2006-2010 for carriers of moderate-high and low-moderate risk mutations, some 10 years later.

CONCLUSION

International management guidelines are critical in building and increasing the pressure towards screening of sporadic-appearing disease and offspring of known gene families by encompassing the complete disease spectrum early on.

[Regional Differences in Thyroid Function Parameters: A Comparison of European Cohort Studies]

AIM OF THE STUDY

The aim of the project was to investigate regional differences in thyroid stimulating hormone (TSH), and free thyroxine (fT4) concentrations and iodine status in comparable German and European cohort studies.

METHODS

Sex- and age-stratified TSH, fT4, and urine iodine concentrations of thyroid-healthy participants (age group 45-75 years) of the HNR (Heinz Nixdorf Recall) Study in the Ruhr region of Germany, the southern German KORA (Cooperative Health Research in the Augsburg Region) and northeastern German SHIP (Study of Health in Pomerania) studies, as well as the Norwegian HUNT (Nord-Trøndelag Health) study (age group 40-79 years), the English EPIC (European Prospective Investigation of Cancer)-Norfolk study, and the Dutch Rotterdam study were compared. The TSH reference range for the HNR study population was calculated and compared to the KORA and SHIP studies.

RESULTS

Regional differences showed a stronger influence on TSH and fT4 concentrations than sex and age of the subjects in the 45- to 75-year age group. The estimated difference in medians, as measured by the HNR study, was lowest in the SHIP study, -0.47 (95% CI: -0.53; -0.41) for men and -0.41 (-0.53; -0.41) for women. The Rotterdam study had the highest difference in medians for both men and women (men: 0.56 with 0.44; 0.68 and women: 0.62 with 0.46; 0.78). The lowest median TSH concentrations, across all age categories considered, were seen in the German cohorts.

CONCLUSIONS

Comparison of thyroid function parameters and iodine in elderly subjects between six comparable cohort studies from Germany and Europe showed a significant influence of region, which exceeded the sex and age dependence of the parameters.

Incidence and survival in patients with urachal carcinoma: Cancer registry analysis between 2008 and 2019

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Background: Urachal carcinoma (UrC) is a rare and poorly studied cancer without evidence-based treatment strategies. Due to the low prevalence of this cancer, only sparse data on its incidence and survival are available. Therefore, we analyzed the incidence and survival rates of patients with UrC in North Rhine-Westphalia (NRW), a state of the Federal Republic of Germany. Methods: UrC (ICD-O-3: C67.7) diagnosed between 2008 and 2019 were identified via the NRW Cancer Registry (population 18 million) and classified according to Mayo-staging and T-category. Mayo stage was based on the TNM classification. We calculated age-standardized incidence rates using the European standard and Kaplan-Meier overall survival (OS). Age was stated as mean and standard deviation (SD). Results: A total of 121 UrC patients were described, of which men were more frequently affected at 57%. The distribution for women was 43%. The mean age was 61.1 (SD: 15.5) years for men and 58.8 (SD: 15.3) years for women. The overall age-standardized incidence rate was 0.43 per 1.000.000 person-years, which was 0.5 for men and 0.37 for women. 85.1% had adenocarcinomas, 6.6% urothelial carcinoma, 4.1% unspecified cancer, 2.5% epithelial carcinomas, 0.8% squamous cell carcinomas or others, respectively. The 5-year OS rate were 60.4% (CI-95%: 48.9%; 74.7%) for men and 41.7% (CI-95%: 28.8%; 60.2%) for women. According to TNM classification, 33% of the patients presented with T1-2, 29.8% with T3-4, while for the Mayo staging a distribution of 17.4% for stage I-II and 13.2% for stage III-IV was shown. Data regarding T-category and Mayo-satging were available in 63.6% (44 patients) and 30.6% (84 patients), respectively. The 5-year OS was 73.3% (CI-95%: 59.3%; 90.6%) in T1-2, 37.2% (CI-95%: 23.6%; 58.6%) in T3-4. and 69.3% (CI-95%: 47.6%; 100%) and 25.6% (CI-95%: 9.89%; 66.49%) in Mayo stage I-II and III-IV, respectively. Conclusions: UrC is a rare cancer and OS rate in NRW were comparable to historical data. The prognosis was stage-dependent and identified poor outcome in patients with advanced disease. Our data underscored the role of proper staging and diagnosis for future clinical studies that investigate optimal treatment strategies.

Clinical Decision Support for Axillary Lymph Node Staging in Newly Diagnosed Breast Cancer Patients Based on 18F-FDG PET/MRI and Machine Learning

In addition to its high prognostic value, the involvement of axillary lymph nodes in breast cancer patients also plays an important role in therapy planning. Therefore, an imaging modality that can determine nodal status with high accuracy in patients with primary breast cancer is desirable. Our purpose was to investigate whether, in newly diagnosed breast cancer patients, machine-learning prediction models based on simple assessable imaging features on MRI or PET/MRI are able to determine nodal status with performance comparable to that of experienced radiologists; whether such models can be adjusted to achieve low rates of false-negatives such that invasive procedures might potentially be omitted; and whether a clinical framework for decision support based on simple imaging features can be derived from these models. Methods: Between August 2017 and September 2020, 303 participants from 3 centers prospectively underwent dedicated whole-body ¹⁸F-FDG PET/MRI. Imaging datasets were evaluated for axillary lymph node metastases based on morphologic and metabolic features. Predictive models were developed for MRI and PET/MRI separately using random forest classifiers on data from 2 centers and were tested on data from the third center. Results: The diagnostic accuracy for MRI features was 87.5% both for radiologists and for the machine-learning algorithm. For PET/MRI, the diagnostic accuracy was 89.3% for the radiologists and 91.2% for the machine-learning algorithm, with no significant differences in diagnostic performance between radiologists and the machine-learning algorithm for MRI (P = 0.671) or PET/MRI (P = 0.683). The most important lymph node feature was tracer uptake, followed by lymph node size. With an adjusted threshold, a sensitivity of 96.2% was achieved by the random forest classifier, whereas specificity, positive predictive value, negative predictive value, and accuracy were 68.2%, 78.1%, 93.8%, and 83.3%, respectively. A decision tree based on 3 simple imaging features could be established for MRI and PET/MRI. Conclusion: Applying a high-sensitivity threshold to the random forest results might potentially avoid invasive procedures such as sentinel lymph node biopsy in 68.2% of the patients.

Skin Cancer Screening and Medical Treatment Intensity in Patients with Malignant Melanoma and Non-Melanocytic Skin Cancer

BACKGROUND

This cohort study concerns the effect of skin cancer screening (SCS) on medical treatment intensity in patients with skin cancer.

METHODS

Routine data from persons aged 35 to 99 who were insured by the AOK health insurance company were used to identify persons who received a diagnosis of malignant melanoma or a non-melanocytic skin cancer in 2014 or 2015, either through skin cancer screening or without screening. These persons were included in cohort studies. The routine data contained no information on tumor stages or grading. Tumor-associated rates of hospital admission, contact with physicians in outpatient practice, and intensity of surgical treatment were determined; rate ratios (RR) and their 95% confidence intervals (CI) were estimated.

RESULTS

The cohort studies included 13 633 patients with melanoma (6480 with SCS and 7153 without) and 118 168 patients with non-melanocytic skin cancer (43 308 with screening and 74 860 without). Patients whose melanomas had been detected by screening had a lower medical treatment intensity than unscreened patients (intensity of tumor-associated surgical treatment (RR = 0.79, 95% CI [0.74; 0.85]), hospital contact rate (RR = 0.44, 95% CI: [0.38; 0.50]), contact with physicians in outpatient practice (RR = 0.79, 95% CI: [0.73; 0.85]). Among patients with non-melanocytic skin cancer, the screened patients displayed a lower hospital contact rate (RR = 0.52, 95% CI: [0.49; 0.56]), a higher contact rate in the outpatient sector (RR = 1.11, 95% CI: [1.08; 1.13]), and no difference in surgical treatment intensity (RR = 0.98, 95% CI: [0.96; 1.00]).

CONCLUSION

SCS is associated with lower medical treatment intensity in the first 12 months after diagnosis in patients with melanoma. Among patients with non-melanocytic skin cancer, those who had been screened had lower hospital contact rates, but there was no observed lowering of other rates reflecting treatment intensity.

Diagnostic Cardiac CT for the Improvement of Cardiovascular Event Prediction

BACKGROUND

The aim of the long-term Heinz Nixdorf Recall Study (observation period 20 years) was to establish the extent to which computed tomography (CT) improves the predictability of cardiovascular events relative to determination of risk factors alone.

METHODS

In the period 2000-2003, study staff examined 4355 probands (53% of them female) aged 45-75 years with no signs of cardiovascular disease. The Atherosclerotic Cardiovascular Disease (ASCVD) score was calculated on the basis of demographic data and cardiovascular risk factors. Cardiac CT was carried out over the same period and coronary artery calcification (CAC) was graded according to the Agatston score.

RESULTS

The median duration of follow-up was 18.2 years for men and 17.8 years for women. Myocardial infarction or stroke occurred in 458 (11%) of the 4154 participants with complete data. Overall, estimation of risk using a combination of ASCVD score and CAC grade was superior to the ASCVD score alone-even after 10 and 20 years. Classification into established risk categories improved by 12.2% (95% confidence interval: [5.3%; 18.1%]). In the highest ASCVD risk category, we observed occurrence of a cardiovascular event over 20 years for 14% [5.0%; 23.1%] of probands with a CAC score = 0 but for 34.2% [27.5%; 41.4%] of those with a CAC score ≥ 400. In the lowest ASCVD risk category, an event occurred in 2.4% [1.4%; 3.7%] of probands with a CAC score = 0 and in 23.5% [2.3%; 35.8%] of those with a CAC score ≥ 400.

CONCLUSION

Even after 20 years, individual risk prediction is improved by addition of CT-based determination of coronary artery calcification to the ASCVD score. Therefore, assessment of ASCVD risk factors should be complemented more widely by cardiac CT in the primary prevention of cardiovascular disease.

[Factors Influencing Results of Mortality Measurement in the Corona Pandemic: Analyses of Mortality in Germany in 2020]

INTRODUCTION

(Excess) mortality and years of life lost are important measures of health risks from the Corona pandemic. The aim of this paper was to identify methodological factors that affect the calculation of mortality and further to point out possible misinterpretations of years of life lost.

METHODOLOGY

Standardized mortality ratios (SMRs) can be used to compare mortalities (e. g., an SMR of 1.015 means excess mortality of 1.5%, an SMR of 0.990 means that mortality is reduced by 1.0%). In this study, SMRs as a measure of association for mortality in Germany were calculated for 2020 using different methods. In particular, the influence of different data sources and reference periods was examined. Furthermore, its influence on the calculated mortality was also examined to take into account increasing life expectancy. In addition, published results on years of life lost were critically analyzed.

RESULTS

Using January 2022 data from the Federal Statistical Office on mortality for 5-year age groups resulted in higher SMR values than using preliminary data from February 2021 with 20-year age groups (SMR=0.997, 95% confidence interval (CI): 0.995-0.999 versus SMR=0.976 (95% CI: 0.974-0.978)). The choice of the reference period had a large impact on calculated mortality (for men, SMR=1.024 (95% CI: 1.022-1.027) with 2019 as the reference year versus SMR=0.998 (95% CI: 0.996-1.001) with 2016 to 2019 as the reference period). Analyses in which declining mortality in 2016 to 2019 was carried forward into 2020 when calculating expected deaths resulted in significantly higher SMR values (for men SMR=1.024 (95% CI: 1.021-1.026) with, and SMR=0.998 (95% CI: 0.996-1.001) without carrying forward declining mortality). Figures for pandemic-related years of life lost per person who died from COVID-19 should be interpreted with caution: Calculation from remaining life reported in mortality tables can lead to misleading results.

CONCLUSION

When calculating mortality and years of life lost during the pandemic, a number of methodological assumptions must be made that have a significant impact on the results and must be considered when interpreting the results.