Incidence trends of pediatric onset inflammatory bowel disease in the years 2000-2009 in Saxony, Germany-first results of the Saxon Pediatric IBD Registry

Aims

In developed countries, the incidence of inflammatory bowel disease (IBD) such as Crohn's disease (CD) and ulcerative colitis (UC) is increasing. Therefore, we aimed to investigate the incidence rates and trends over time in the population of children and adolescents in one of the federal states of Germany, in Saxony.

Methods

Over the 10-year period 2000–2009 all 31 children’s hospitals and pediatric gastroenterologists, respectively in Saxony reported all IBD patients up to 15 years of age to the Saxon Pediatric IBD Registry. The completeness of the registry was estimated as 96.7% by independent surveys in the years 2005–2009. Incidence rates were presented as age-standardized incidence rates (ASR) regarding New European Standard Population 1990 per 100,000 person-years (PY) with 95% confidence intervals [CI]. Joinpoint and linear regression was used for trend analyses.

Results

344 patients with confirmed IBD between 2000–2009 were included in the epidemiological evaluation: 212 (61.6%) patients with CD, 122 (35.6%) with UC and 10 (2.9%) with unclassified IBD (IBD-U). The ASR per 100,000 PY over the whole observation period was 7.2 [6.4–7.9] for IBD, 4.4 [3.8–5.0] for CD, 2.6 [2.1–3.0] for UC and 0.2 [0.1–0.3] for IBD-U. For IBD, the ASR per 100,000 PY increased from 4.6 [2.8–6.3] in 2000 to 10.5 [7.5–13.6] in 2009. The incidence trend analysis of ASRs using the joinpoint regression confirmed a significant increase of IBD as well as UC. The mean age at first diagnosis decreased significantly during the observation period from 11.5 (11.0–13.4) in 2000 to 9.6 (5.1–13.5) years in 2009. The median of the diagnostic latency among IBD patients was 3 months.

Conclusion

The incidence of IBD in children and adolescents in Saxony was slightly higher than the average of other countries in the same time period and followed the trend towards a general increase of IBD. The age at diagnosis was subject to a very unfavorable downward trend.

Recommendations of the German Association for Medical Informatics, Biometry and Epidemiology for Education and Training in Medical Informatics

In the fields of health care and medicine there is an immense demand for a systematic application of methods of information processing and for the use of computers. Obviously, to that end well-trained scientists and qualified personnel must be available. With the present recommendations on education and training in medical informatics the German Association for Medical Informatics, Biometry and Epidemiology (GMDS) proposes structure and contents of medical informatics curricula and courses. The recommendations describe a 2-dimensional educational framework with different educational levels in one dimension and various types of educational needs and orientation in the other one. The recommendations comprise at the university level education as well specialized curricula covering the total spectrum of medical informatics as well as informatics curricula with medical informatics as integrated applied subject or subsidiary subject, respectively. Besides these informatics-oriented approaches medical-oriented programs of education in medical informatics are recommended, e.g., post-graduate education in medical informatics for physicians based on foundations in medical informatics as part of their initial training in medicine. At the level of polytechnical schools curricula of medical documentation and informatics and at the level of professional schools training in medical documentation are recommended. This report is a translation of its German original. Although considered by the GMDS as recommendations for the Federal Republic of Germany, the text may also contribute to the development of an international, especially European framework of training in medical informatics.

Incidence of childhood diabetes in children aged less than 15 years and its clinical and metabolic characteristics at the time of diagnosis: data from the Childhood Diabetes Registry of Saxony, Germany

AIMS

The Childhood Diabetes Registry in Saxony, Germany, examined the incidence and metabolic characteristics of childhood diabetes.

METHODS

In the federal state of Saxony, newly diagnosed cases of diabetes in children and adolescents aged less than 15 years were registered continuously from 1999 until 2008. Family history, date of diagnosis, clinical and laboratory parameters were obtained. Reported cases were ascertained by public health departments as an independent data source and verified using the capture- recapture method.

RESULTS

A total of 865 children and adolescents with newly diagnosed diabetes were registered in Saxony. About 96% of them were classified as having type 1 diabetes, 0.6% had type 2 diabetes, 2.4% had maturity-onset diabetes of the young (MODY), and 1.4% had other types of diabetes. The age-standardized incidence rate of type 1 diabetes was estimated at 17.5 per 100,000 children per year. Completeness of ascertainment as calculated by the capture-recapture method amounted to 93.6%. At the time of diagnosis, 27.1% of children with type 1 diabetes had ketoacidosis, 1.5% had a blood pH <7.0, and 1.1% were unconscious.

CONCLUSION

The registry provided data about the incidence rates and clinical presentation of childhood diabetes in a defined German population. We observed higher incidence rates compared to previous surveys.

Evaluation of a diabetes management system based on practice guidelines, integrated care, and continuous quality management in a Federal State of Germany: a population-based approach to health care research

OBJECTIVE

The aim of this study was to evaluate the Saxon Diabetes Management Program (SDMP), which is based on integrated practice guidelines, shared care, and integrated quality management. The SDMP was implemented into diabetes contracts between health insurance providers, general practitioners (GPs), and diabetes specialized practitioners (DSPs) unified in the Saxon association of Statutory Health Insurance Physicians.

RESEARCH DESIGN AND METHODS

The evaluation of the SDMP in Germany represents a real-world study by using clinical data collected from participating physicians. Between 2000 and 2002 all DSPs and about 75% of the GPs in Saxony participated. Finally, 291,771 patients were included in the SDMP. Cross-sectional data were evaluated at the beginning of 2000 (group A1) and at the end of 2002 (group A2). A subcohort of 105,204 patients was followed over a period of 3 years (group B).

RESULTS

The statewide implementation of the SDMP resulted in a change in therapeutic practice and in better cooperation. The median A1C at the time of referral to DSPs decreased from 8.5 to 7.5%, and so did the overall mean. At the end, 78 and 61% of group B achieved the targets for A1C and blood pressure, respectively, recommended by the guidelines compared with 69 and 50% at baseline. Patients with poorly controlled diabetes benefited the most. Preexisting regional differences were aligned.

CONCLUSIONS

Integrated care disease management with practicable integrated quality management including collaboration between GPs and specialist services is a significant innovation in chronic care management and an efficient way to improve diabetes care continuously.

[Rigid RSA DMP for Type-2 Diabetes Mellitus: results of a three-state survey]

Diabetes contracts, such as those used in Saxony, were already excellent, effective diabetes programs in line with the concept of disease management. This was due to well-accepted practical guidelines and to an integrated care concept that was implemented with little bureaucratic effort through an internal quality-control management; this was based in turn on rapid, practicable documentation in the framework of interdisciplinary quality round tables. The present RSA DMP, in contrast, are to be fundamentally improved and simplified. This must occur also in view of the handling of guidelines, so that these do not jeopardize well-established and positively-evaluated healthcare programs (and along with that the quality of patient care) in the regions with well-functioning systems. In view of the persistent critiques on form and content of the state-regulated chronic-disease programs, the group "DMP in Central Germany", representing the German federal states of Saxony, SaxonyAnhalt, and Thuringia, initiated at the end of 2003 a structured survey for the evaluation of the RSA DMP Type 2 Diabetes among general practitioners and diabetes specialists. Particularly critical evaluations of the RSA DMP originate from the federal states with well-developed guideline-based diabetes care programs, for example in the new Eastern federal states, Nord Rhine-Westphalia, and Bavaria. With its minimal standards, the RSA DMP does not represent any progress in these regions and does not contribute to cost reduction. Detailed medical contents and professional guidelines do not belong to a law ordinance but to the already existing medical guidelines.

[Improvement of care for diabetics using the care model from Saxony]

BACKGROUND AND OBJECTIVE

By promoting the networking of all those involved in caring for diabetics in Saxony, through agreement between those who provide help to them and the organizations which pay the costs, the intention is to improve the overall quality of care of diabetics. It was the aim of this study to evaluate the effectiveness of this integrated health model.

PATIENTS AND METHODS

As part of the 3rd Diabetes Agreement in Saxony, a total of 275,804 diabetics were registered, treated and their management costed in the first quarter of 2000 and the fourth quarter of 2001 (56.3% females, 43.7% males; median age 68,7 years). They were patients of 2800 general practitioners and 88 specialist practices.

RESULTS

Nearly 80% of all diabetics were included. Taking the level of HbA1c as the criterion of quality achieved, it had decreased from 7,1 +/- 1,3 % in the first 3 months of 2000 to 6,8 +/- 1,3 % in the last 3 months of 2001, and regional differences had been reduced. There was an obvious correlation between early referral to specialist practices and good treatment results, as measured by HbA1c and blood pressure levels. While in 1996 patients were referred when the HbA1c level was 8.8% (median 8.5%), referrals in the last quarter of 2001 were made when the mean was 8,0% (median 7.7%). After two years the risk of inadequate treatment (HbA1c > 7.5% and blood pressure > 140/90 mmHg) had been clearly reduced in about half the cases.

CONCLUSIONS

Diabetes agreements, as promulgated in Saxony, have provided effective disease management programs (DMP) for efficacious and efficient integrated diabetic care, so that with continuing effectiveness and further development the St. Vincent targets can be reached. Successful regional diabetes agreements must therefore be maintained within the new, politically centralized, DMPs.

Primary breast cancer therapy in six regions of Germany

Studies from six regions of Germany (Aachen (W1), Dresden (E1), Jena (E2), Marburg (W2), Munich (W3), and Stuttgart (C1)) have been compared to verify and assess the quality of healthcare using breast cancer as an example. All of the data collection was carried out in comprehensive cancer centres and is population-based, with the exception of C1. Classic prognostic factors and the initial treatment of 8661 women with breast cancer, diagnosed between 1996 and 1998, were examined. Primary therapy, breast conserving therapy (BCT), and the use of subsequent local radiation and/or systemic therapy (chemotherapy or hormonal therapy) were analysed. BCT was performed on 39.3-57.7% of patients. By pT-category, the proportion of BCT in the six regions were as follows: for pTis between 37.8 and 64.3%, for pT1 between 51.7 and 71.5%, for pT2 between 25.9 and 51.1%, for pT3 between 0 and 13.1% and for pT4 between 0 and 15.2%. Multivariate analyses, adjusted for age and biological factors, showed a significant influence of the treating hospital on the mastectomy rate. The use of radiotherapy after BCT (80%) was quite homogeneous in the six regions. The application of radiotherapy after mastectomy, however, varied between 10.4 and 32.2%. In all regions, for premenopausal patients, the use of adjuvant systemic therapy almost reflected the St. Gallen-Consensus recommendations. In contrast, post-menopausal women with positive lymph nodes were not always treated according to these standards. In all regions, age had an influence on the administration of treatment: elderly breast cancer patients received less BCT, less radiotherapy and less adjuvant therapy than recommended in the St. Gallen-Consensus. Feedback of the results was made available to each hospital, providing a comparative summary of patient care that could be used by the participating hospitals for self-assessment and quality-control.

Development of an oncology data network in Germany

In the 1990ies, an oncology data network has been set up mainly in the New States of Germany. Although not formally planned and established as a whole, it consists of a number of initiatives, that co-operate well and gain added value from this co-operation. From the technological view, the centre of the network is the Giessener Tumordokumentationssystem (GTDS), that was developed at Giessen University. We present important basic conditions in which this development took place, show some results and describe future directions of the development.

Manifest diabetes and keratoconus: a retrospective case-control study

PURPOSE

To assess the influence of diabetes on the development of keratoconus to show whether biomechanical effects are also reflected in epidemiology. The two diseases have opposite impact on the biomechanics of the corneal stroma: manifest diabetes stiffens the cornea, whereas keratectasia weakens the tensile strength of the stroma.

METHODS

The retrospective case-control study included files of 1,142 patients, with 571 patients in the case group (keratoconus patients) and 571 in the control group (clinical population). The groups were well matched with respect to sex and age. We established the number of diabetics in both groups and compared it statistically by means of the odds ratio to determine whether diabetes can be interpreted as having a "protective effect" whether it is a "risk factor" for the development of keratoconus.

RESULTS

Two patients of the keratoconus group had manifest diabetes that developed many years after the diagnosis of keratoconus, while nine cases of diabetes were found in the control group. Statistical analysis revealed a strong protective effect of manifest diabetes regarding keratoconus (odds ratio = 0.2195, P = 0.034). This effect was evident only in type II diabetes patients.

CONCLUSIONS

The protective effect of manifest diabetes may be explained by the induction of cross-links in the stroma, preventing biomechanical weakening of the cornea. This study shows that different biomechanical changes can be superimposed and assume epidemiological relevance.

[Medical guidelines for diabetes mellitus in Saxony. An instrument for interdisciplinary quality management for optimizing patient care]

Patients with diabetes still have a life expectancy of 5-10 years less and a markedly reduced quality of life than non-diabetic persons. Concepts, models, and contracts aiming at an efficient co-operative care for chronically ill patients have been developed in the new German states to overcome shortage of care. The dual care of motivated diabetic patients by family physicians and experts for metabolic diseases has proven to be efficient both in pilot studies as well as in country-wide investigations. A representative commission for diabetes has developed guidelines for such a structure of dual care. Design and content of these regional developed guidelines about an cooperative evidence based care for diabetic patients fulfills the criteria suggested by international bodies of experts and the medical society for quality assurance. The Saxonian guidelines for diabetes have been successfully implemented step by step in medical offices and hospitals. We are sure that the further implementation of the shared care system diabetes will further improve quality of care.

[Quality of diabetes management in the free Saxony state--scientific evaluation of the Saxony model for managing diabetes. EVA group]

After the societal change in the "New Federal States" of Germany Saxon diabetologists developed an integrated concept for care of diabetic patients: the Saxon Care Model (SCM). It aims at quality assurance in diabetes care and is based on services by cooperating general practitioners and specialists. This model was evaluated. First results were obtained describing the quality of care for 510 patients at baseline. This sample was collected at two specialized diabetologists (level 2), two specialized out-patient units at universities (level 2) and two general practitioners (level 1). The design of the study is a descriptive evaluation. Process and outcome quality at specialized and primary care units working according to the SCM is relatively high. HbA1c measurements were taken in order to quantify outcome quality. The results for primary as well as specialized care units ranged from acceptable to very good. They unfortunately cannot be generalized. The patients expressed that their quality of life was limited only scarcely. The presented preliminary results indicate a high effectiveness of the SCM with regard to relevant process-related outcome-variables. The large variance between single practices of both levels demonstrates that deficits in early diagnosis of diabetes-related complications still exist. On the other hand this points towards resources of quality improvement. The influence of quality assuring measures, e.g. quality circles, will be assessed in a three-year follow up.

Recommendations of the German Association for Medical Informatics, Biometry and Epidemiology for education and training in medical informatics

In the fields of health care and medicine there is an immense demand for a systematic application of methods of information processing and for the use of computers. Obviously, to that end well-trained scientists and qualified personnel must be available. With the present recommendations on education and training in medical informatics the German Association for Medical Informatics, Biometry and Epidemiology (GMDS) proposes structure and contents of medical informatics curricula and courses. The recommendations describe a 2-dimensional educational framework with different education levels in one dimension and various types of educational needs and orientation in the other one. The recommendations comprise at the university level education as well specialized curricula covering the total spectrum of medical informatics as well as informatics curricula with medical informatics as integrated applied subject or subsidiary subject, respectively. Besides these informatics-oriented approaches medical-oriented programs of education in medical informatics are recommended, e.g., post-graduate education in medical informatics for physicians based on foundations in medical informatics as part of their initial training in medicine. At the level of polytechnical schools curricula of medical documentation and informatics and at the level of professional schools training in medical documentation are recommended. This report is a translation of its German original. Although considered by the GMDS as recommendations for the Federal Republic of Germany, the text may also contribute to the development of an international, especially European framework of training in medical informatics.

Investigations on biochemical properties of milk-clotting enzymes

The properties of proteolytic enzymes produces from calf maws and from an Ascomycete were studied. Both milk-clotting proteases have their optimum activity at pH 5.2 and 45 degrees C. The microbiological rennin has a second maximum activity at pH 3.5 and 55 degrees C. Temperatures above 55 degrees C cause a rapid decrease of activity. The behaviour of enzyme activity is similar with varying substrate and enzyme concentrations. However, increasing amounts of enzyme in ratio to the substrate lead to reaction rates of the calf rennin differing clearly from that of the microbiological rennet complex.

[Epidemiologic aspects of disability caused by rheumatic diseases in the Gera district, East Germany]

In the period 1968-1977, the mean annual invalidization rates due to rheumatic diseases in the district of Gera are 36.6 for the female insured population, 19.3 for the male one, per 10(5) persons. After the age of 40, invalidization rates are rising steeply. Degenerative arthropathies (osteoarthroses and displacements of the intervertebral disk or vertebrogenic pain syndromes) constitute more than four fifths of all first-time invalidizations. First-time invalidization was done, on average, 7 years before reaching the age-limit provided by law for old-age pension, in one third temporally limited. The longitudinal monitoring of the invalidzation rates supports the hypothesis that clinical manifestations of degenerative arthropathies are increasing.

Virulence properties of Escherichia coli strains in patients with chronic pyelonephritis

In 50 Escherichia coli strains obtained from the bladder puncture urine of patients with chronic pyelonephritis, determinations of virulence properties were performed. All of the E. coli strains isolated from 26 acute episodes of pyelonephritis were found in the smooth form. 30% possessed K 1 antigen, 77% showed the ability to form hemolysin and 30% produced colicin V (aerobactin). Fimbriae (detected by mannose-resistant hemagglutination) were registered in 81%, and plasmids ranging between 50 and 70 Md were demonstrated in 70% of the bacteria. In contrast to this, only 70% of the E. coli strains isolated from 24 patients at an inactive stage of pyelonephritis were found in the smooth form; 10% of these encoded K 1 antigen, 20% hemolysin and 10% colicin V. Plasmids in the range 50 to 70 Md could be found in 30%. On the basis of multivariate analysis of variance and discriminant analysis, it was confirmed that uropathogenic strains possess several virulence properties, mannose-resistant hemagglutination being of particular importance.

[Personal experiences with conservative drug therapy of urgency symptoms in the female]

On the basis of clinical and urodynamic results the authors adopt a definite attitude to the treatment of the urgency syndrome in the woman with the anticholinergic drug propiverin hydrochloride (Mictonorm). The results show a satisfactory improvement in 42 of 68 women (= 62%), whereas 24 of 68 women (= 35%) reported a subjective improvement of the clinical symptoms. These results correspond with the data from literature. In 15 women with no satisfactory effect the beta 2-sympathicomimetic drug clenbuterol (Contraspasmin) was additionally applied. There was a satisfactory success under this medication in 11 of the 15 women (= 72%). The results are discussed with the references of the literature to the conservative therapy of the urgency syndrome.

[Changes in the parameters of the urethral pressure profile by measuring the patient in supine and sitting position]

For testing the influence of the examination position on the parameters of the urethrocystometry 124 findings of urethrocystometry of 103 female patients were evaluated in 3 groups. In these cases slight alterations develop when changing between lying and sitting position, whereby in sitting position a greater differentiation of an existing component of stress incontinence becomes possible. On the basis of our examination findings and the references in literature it seems to be advisable to perform the urethrocystometry in the same session both in lying and in sitting position for further improvement of the indication for therapy.

Nasal polyposis, bronchial asthma and analgesic intolerance

A retrospective case-control study was conducted in 1042 arbitrarily selected bronchial asthma patients (197 patients with AIA and 845 controls with normal analgesic tolerance). Two thirds of all AIA patients reported one or more diseases in the region of the upper airways. Quite different from the control group, highly significant coincidence of AIA with nasal polyposis (42.6%), paranasal sinus diseases (39%), and chronic rhinitis (42,1%) was recorded in the AIA patients. AIA was characterized by stronger inclination to recurrence of nasal polyps and more frequent negative impact of polypectomy upon the course of asthma. The classical triad of "intrinsic asthma - nasal polyps - analgesic intolerance" was established in 39% of the AIA patients. The pathogenetic factors causing the association of asthma with polyps and the even more strongly association of AIA with polyps are still unknown. The presumed pathogenetic relationship between chronic hyperplastic alterations in the upper airways and the phenomenon of AIA might be caused by disorders in phospholid metabolism (liberation of arachidonic acid, lipoxygenase products, radical mechanisms).

Carpal tunnel syndrome--course and prognosis

In a retrospective study 157 patients with electrophysiologically proven carpal tunnel syndrome (CTS) were followed up. Of the 85 operatively treated patients, 86% showed clear improvement or cure, as did 32% of the patients not operated upon. Multivariate analysis of variance (MANOVA) and linear discriminant analyses indicated atrophy and length of history as effective predictors of clear improvement. The optimized discriminant point was ascertained in the receiver operator characteristics (ROC) curve. A predictive value of positive test of 0.89 was found for the course form "not cured" and a predictive value of negative test of 0.75 for the course form "cured" with a prevalence of one-third for the good course form. The prognosis was bad if atrophy occurred or the history exceeded 7 months. The determination of distal motor latency is indispensable for diagnosing CTS. For prognosis, however, length of history and clinical findings have been more helpful.

[Computerized analysis of intrapartum cardiotocograms]

307 monitored labors were investigated by means of a discrimination function (DF) in relation to qualitative CTG-parameters. In this connection we could confirm on the one hand well defined qualitative CTG-criteria in their clinical importance by computation corresponding to "normal", "prepathological" (warning-signs) and "pathological" (signs of hypoxia). On the other hand we could demonstrate the exactly recognition of qualitative CTG-parameters in attendance of computation. The boundary ranges of discrimination function resulting from the automatic CTG-analysis respecting fetal condition turned out to be reproduced and clinically reliable. The prediction with regard to neonatal parameters (pHNA, APGAR-score 5 minutes after delivery) is justifying the employment of present soft ware in clinical practice.

[The "robotron NATALI" microcomputer-assisted birth monitoring system]

The microcomputer system "robotron-NATALI" from VEB Kombinat robotron Dresden, GDR, is applicable for bed side-monitoring and disposed about a new graphical representation of CTG's for fetal condition and uterine activity. A dialogue between physician or nurse and the computer is possible. After parturition all administered data are printed out in form of a partogram, inclusive the graphical representations during labor.

[A new form of representation of foetal cardiotocograms (author's transl)]

Based on a computerized analysis of CTG's we have developed a new graphical representation of fetal CTG's. The reproduction results from displays over 13 hours labor-progressing. A mathematical model is used. We have applied a discrimination function (DF) which is composed by 10 quantitative electronic parameters. Two fixed periods are compared. For mathematical and statistical evaluation the multivariate analysis of variance in connection with methods of dimension-reduction and discrimination was applied. A nonelementary discrimination function was taken into account. The value of the discrimination function was checked by means of postnatal data (pHNA and APGAR-score 5 minutes postnatal). The predictability "normal" pHNA - related to the computerized CTG- analysis - was exact in 80% (pHNA greater than or equal to 7,20). In 20% we found prepathological pHNA-values (pHNA:7,19-7,11). The predictability "prepathological" pHNA - related to the computerized CTG- analysis - was in 3,5% correlated with pathological pHNA-values (pHNA less than or equal to 7,10). Pathological pHNA - values may be almost ruled out by computerized CTG - analysis. Computerized "normal" CTG's were in 97% correlated with APGAR-scored values (5 minutes postnatal) > 7. Computerized "prepathological" or "pathological" CTG's were in 26% correlated with APGAR-score values (5 minutes postnatal) less than or equal to 7. The proposed computer-program is already used in this form in clinical practice.

[Morbidity studies, following continuous electronic and biochemical monitoring of 1,000 childbirths (author's transl)]

A group of 1,000 electronically and biochemically monitored children of high-risk deliveries was examined for morbidity up to the age of one year.--Transfer to the Paediatric Hospital of Jena University had been necessary for 147 newborns for low weight and/or impaired adaptation. Sixteen of 18 neurologically conspicuous children, which had temporarily displayed electro-encephalographic or echo-encephalographic pathological or marginal findings, did no longer exhibit any neurological deficiency or signs of impaired intelligence, when re-examined after ten months. Only two children had severe disorders in terms of infantile cerebral paresis, one of them with a genetically determined disease (Morbus Langdon Down).--Incidence of infantile cerebral paresis dropped from more than three to something between one and two per cent owing the antepartum, intrapartum, and postpartum intensive monitoring as well as to intensive neonatal care. It is assumed that this will act to decrease the number of children with mental retardation.

[Relationship between clinical parameters and labor (author's transl)]

In 200 cases of childbirth supervised by intra-amniotic tocometry the relations between various clinical parameters such as age, parity, gestosis, rise of temperature, birth weight, small circumference of the head, duration of the cervical dilatation and the expulsion period, and the exactly defined motility of the uterus were investigated during different phases. The results confirmed the very limited influence of selected clinical phenomena upon the multifactiorially regulated total complex of labour.