Retrospektive Analyse der Lösungsorientierten Maltherapie (LOM®) zur Behandlung von Patienten mit starken und langandauernden Belastungssituationen

Mittlerweile gehören künstlerische Therapien vermehrt den multimodalen Therapieansätzen medizinischer Fachbereiche an, was sich in einigen S3-Leitlinien widerspiegelt. Ein Forschungsinteresse an der Kunsttherapie besteht schon seit langem, jedoch mangelt es in der Studienlage an standardisierter Berichtserstattung und oft sind nur vage Beschreibungen der zugrunde liegenden Behandlungsmaßnahmen angegeben, was die Bestimmung der Studienverfahren deutlich erschwert. Eine therapeutische Wirksamkeit der Kunsttherapie wird häufig in der nichtsprachlichen, emotionalen Kommunikation und Expression vermutet. Im Kontrast dazu steht die hier untersuchte „Lösungsorientierte Maltherapie – LOM®“, welche von Fr. Dr. Bettina Egger und Jörg Merz seit 1980 entwickelt wurde. LOM besitzt ein klar nachvollziehbares Therapiemanual mit sehr strukturierten Flowcharts zur Behandlung verschiedenster Anliegen mit Belastungen. Bei der LOM findet keine klassische Analyse oder Interpretation der Bilder statt. Die Lösung des Anliegens steht im Zentrum. Ein weiterer wesentlicher Unterschied ist die Beschäftigung mit dem Eindruck, den das gemalte Bild beim Patienten erzeugt und nicht dem Ausdruck oder der Expression von Emotionen. Die vermutete Wirkungsweise der LOM liegt darin, dass neu gemalte nicht belastendende Bilder abgespeichert werden und die emotional belasteten Erinnerungen durch einen strukturiert geführten Malprozess „übermalt“ werden. Neurobiologische Forschungsergebnisse zu dem Einfluss von emotionalen Belastungssituationen auf den Menschen unterstützen diesen Erklärungsansatz. Ziel dieser Arbeit ist die Analyse des kurzfristigen und langfristigen Outcomes der LOM anhand eines Patientenkollektives von 60 Patienten mit starken und langfristigen Belastungssituationen. Frau Dr. Egger bearbeitete alle Fälle selbst im Einzelsetting in ihrer Praxis. Die Patienten malten mit der nicht dominanten Hand, stehend an der Wand. Die Datenerhebung erfolgte mit Hilfe von standardisierten Fragebögen und detaillierter Dokumentation der Therapiestunden sowie mit Nachkontrollen nach Beendigung der Therapie. Zur Einschätzung des Ausmaßes der Belastung wurde das Ausmaß der Belastung = Subjective Units of Distress (SUD nach Wolpe), die positive Annäherung (PA nach Egger und Merz) an das gewünschte Ziel und die Stimmigkeit der positiven Kognition = Validity of Cognition (VoC nach Shapiro) abgefragt. Die Parameter wurden zu vier Messzeitpunkten erhoben: direkt vor und nach der maltherapeutischen Intervention, zeitnah nach Therapieende und mindestens 7 Monate bis hin zu 57 Monaten nach Therapieende. Es wurden die Durchschnittswerte und die Standardabweichung (in Klammern) für das Kollektiv ermittelt. Zu den vier Messzeitpunkten wurden folgende Werte erhoben: SUD - Reduktion der Belastung 8,5 (1,3); 1,6 (1,7); 1,4 (1,4); 0,8 (1,2), PA - positive Annäherung an das formulierte Therapieziel 3,2 (2,2); 8,2 (1,7); 8,4 (1,5); 9,0 (1,7) und VoC - positive Kognition 2,9 (1,5); 6,0 (0,9); 6,0 (1,0); 6,5 (0,8). Die Differenz zwischen den Ausgangswerten und den Werten bei Therapieende sowie den Werten bei der Langzeit-Verlaufskontrolle zeigten eine signifikante Belastungsreduktion (SUD: -7,0 (2,2); 0,8 (1,2); p=<0,0001), eine signifikant positive Annäherung an das formulierte Therapieziel (PA: 4,9 (2,6); 9,0 (1,7); p=<0,0001) und eine signifikant gesteigerte positive Kognition (VoC: 3,1 (1,9); 6,5 (0,8); p=<0,0001). Diese erste Beobachtungsstudie evaluierte ein standardisiertes Verfahren einer kunsttherapeutischen Intervention, noch nicht randomisiert und ohne Kontrollgruppe. Das Ergebnis zeigt sehr viele Anhalte für eine kurz- und langfristige Wirksamkeit der LOM zur signifikanten Reduktion von langandauernden und schweren Belastungen unterschiedlicher Genese und bildet somit eine sehr gute Grundlage für die weitere wissenschaftliche Evaluation. Studien mit entsprechend ausgebildeten unterschiedlichen LOM-Therapeuten, Hinzunahme weiterer klinischer Messinstrumente, größere Patientenkollektive und ein prospektives, randomisiertes kontrolliertes Studiendesign wären anzustreben, um diese Ergebnisse zu überprüfen. Von weiterem wissenschaftlichem Interesse wäre die Wirkung der LOM bei Patienten mit anderen psychischen Belastungen bei beispielsweise Tumorleiden oder chronischen Erkrankungen

p53 and p16 expression profiles in vulvar cancer:a translational analysis by the Arbeitsgemeinschaft Gynäkologische Onkologie Chemo and Radiotherapy in Epithelial Vulvar Cancer study group

Background: There are 2 known pathways for tumorigenesis of vulvar squamous cell carcinoma—a human papillomavirus–dependent pathway characterized by p16 overexpression and a human papillomavirus–independent pathway linked to lichen sclerosus, characterized by TP53 mutation. A correlation of human papillomavirus dependency with a favorable prognosis has been proposed. Objective: The objective of the study was to further understand the role of human papillomavirus and p53 status in vulvar squamous cell carcinoma and characterize its clinical relevance. Study Design: The Arbeitsgemeinschaft Gynaecological Oncology Chemo and Radiotherapy in Epithelial Vulvar Cancer-1 study is a retrospective cohort study of 1618 patients with primary vulvar squamous cell carcinoma Fédération Internationale de Gynécologie et d'Obstétrique stage ≥1B treated at 29 gynecologic cancer centers in Germany between 1998 and 2008. For this translational substudy, formalin-fixed paraffin-embedded tissue was collected. A tissue microarray was constructed (n=652 samples); p16 and p53 expression was determined by immunohistochemistry. Human papillomavirus status and subtype were analyzed by polymerase chain reaction. Results: p16 immunohistochemistry was positive in 166 of 550 tumors (30.2%); p53 staining in 187 of 597 tumors (31.3%). Only tumors with available information regarding p16 and p53 immunohistochemistry and without p53 silent expression pattern were further analyzed (n=411); 3 groups were defined: p53+ (n=163), p16+/p53− (n=132), and p16−/p53− (n=116). Human papillomavirus DNA was detected in 85.6% of p16+/p53− tumors; human papillomavirus-16 was the most common subtype (86.3%). Patients with p16+ tumors were younger (64 vs 72 years for p53+, respectively, 69 years for p16−/p53− tumors; P<.0001) and showed lower rates of lymph-node involvement (28.0% vs 42.3% for p53+, respectively, 30.2% for p16−/p53− tumors; P=.050). Notably, 2-year-disease-free and overall survival rates were significantly different among the groups: disease-free survival, 47.1% (p53+), 60.2% (p16−/p53−), and 63.9% (p16+/p53−) (P<.001); overall survival, 70.4% (p53+), 75.4% (p16−/p53−), and 82.5% (p16+/p53−) (P=.002). In multivariate analysis, the p16+/p53− phenotype showed a consistently improved prognosis compared with the other groups (hazard ratio, 0.66; 95% confidence interval, 0.44–0.99; P=.042). Conclusion: p16 overexpression is associated with an improved prognosis whereas p53 positivity is linked to an adverse outcome. Our data support the hypothesis of a clinically relevant third subgroup of vulvar squamous cell carcinoma with a p53−/p16− phenotype showing an intermediate prognosis that needs to be further characterized

Risk for pelvic metastasis and role of pelvic lymphadenectomy in node-positive vulvar cancer - results from the AGO-VOP.2 QS vulva study

Simple Summary In node-positive vulvar squamous cell cancer, questions of when and how to perform pelvic lymphadenectomy (LAE) as well as the optimal extent of pelvic treatment in general have been surrounded by considerable controversy. In Germany, systematic pelvic LAE is currently recommended as a staging procedure in patients at risk for pelvic nodal involvement in order to prevent morbidity caused by pelvic radiotherapy (RT) in patients without histologically-confirmed pelvic involvement. However, the population at risk for pelvic metastases remains insufficiently described, resulting in the potential overtreatment of a considerable proportion of patients with groin-positive disease. This applies to the indication to perform surgical staging but also to adjuvant RT of the pelvis without previous pelvic staging. Our study aims to describe the risk for pelvic lymph node metastasis with regard to positive groin nodes and to clarify the indication criteria for pelvic treatment in node-positive vulvar cancer. Abstract The need for pelvic treatment in patients with node-positive vulvar cancer (VSCC) and the value of pelvic lymphadenectomy (LAE) as a staging procedure to plan adjuvant radiotherapy (RT) is controversial. In this retrospective, multicenter analysis, 306 patients with primary node-positive VSCC treated at 33 gynecologic oncology centers in Germany between 2017 and 2019 were analyzed. All patients received surgical staging of the groins; nodal status was as follows: 23.9% (73/306) pN1a, 23.5% (72/306) pN1b, 20.4% (62/306) pN2a/b, and 31.9% (97/306) pN2c/pN3. A total of 35.6% (109/306) received pelvic LAE; pelvic nodal involvement was observed in 18.5%. None of the patients with nodal status pN1a or pN1b and pelvic LAE showed pelvic nodal involvement. Taking only patients with nodal status ≥pN2a into account, the rate of pelvic involvement was 25%. In total, adjuvant RT was applied in 64.4% (197/306). Only half of the pelvic node-positive (N+) patients received adjuvant RT to the pelvis (50%, 10/20 patients); 41.9% (122/291 patients) experienced recurrent disease or died. In patients with histologically-confirmed pelvic metastases after LAE, distant recurrences were most frequently observed (7/20 recurrences). Conclusions: A relevant risk regarding pelvic nodal involvement was observed from nodal status pN2a and higher. Our data support the omission of pelvic treatment in patients with nodal status pN1a and pN1b

Risk factors for ectopic pregnancy in Germany: a retrospective study of 100,197 patients

Aim: The goal of this study was to identify potential risk factors for ectopic pregnancy in women followed in German gynecological practices.Methods: The present study included pregnant women diagnosed with ectopic pregnancy and pregnant women without ectopic pregnancy followed in 262 gynecological practices between January 2012 and December 2016. The effects of demographic and clinical variables on the risk of developing ectopic pregnancy were estimated using a multivariate logistic regression model. Results: This study included 3,003 women with ectopic pregnancy and 97,194 women without ectopic pregnancy. The mean age was 31.4 years (SD=5.9 years) in ectopic pregnancy patients and 31.1 years (SD=5.6 years) in non-ectopic pregnancy patients. Women aged 36–40 (OR=1.12) and 41–45 years (OR=1.46) were at a higher risk of ectopic pregnancy than women aged 31–35 years. Prior ectopic pregnancy was strongly associated with a risk of recurring ectopic pregnancy (OR=8.17). Prior genital surgery (OR=2.67), endometriosis (OR=1.51), and eight other gynecological diseases were also positively associated with ectopic pregnancy (ORs ranging from 1.19 to 2.06). Finally, there was a 1.80-fold increase in women previously diagnosed with psychiatric disorders.Conclusions: Prior ectopic pregnancy and prior genital surgery were strongly associated with ectopic pregnancy in women followed in German gynecological practices. Psychiatric diseases had an additional impact on the risk of ectopic pregnancy

Data from: Risk factors for ectopic pregnancy in Germany: a retrospective study of 100,197 patients

Aim: The goal of this study was to identify potential risk factors for ectopic pregnancy in women followed in German gynecological practices. Methods: The present study included pregnant women diagnosed with ectopic pregnancy and pregnant women without ectopic pregnancy followed in 262 gynecological practices between January 2012 and December 2016. The effects of demographic and clinical variables on the risk of developing ectopic pregnancy were estimated using a multivariate logistic regression model. Results: This study included 3,003 women with ectopic pregnancy and 97,194 women without ectopic pregnancy. The mean age was 31.4 years (SD=5.9 years) in ectopic pregnancy patients and 31.1 years (SD=5.6 years) in non-ectopic pregnancy patients. Women aged 36–40 (OR=1.12) and 41–45 years (OR=1.46) were at a higher risk of ectopic pregnancy than women aged 31–35 years. Prior ectopic pregnancy was strongly associated with a risk of recurring ectopic pregnancy (OR=8.17). Prior genital surgery (OR=2.67), endometriosis (OR=1.51), and eight other gynecological diseases were also positively associated with ectopic pregnancy (ORs ranging from 1.19 to 2.06). Finally, there was a 1.80-fold increase in women previously diagnosed with psychiatric disorders. Conclusions: Prior ectopic pregnancy and prior genital surgery were strongly associated with ectopic pregnancy in women followed in German gynecological practices. Psychiatric diseases had an additional impact on the risk of ectopic pregnancy

Breast Centers in Germany

A decrease in medical practice variations in national breast cancer care has been shown to improve survival and the negative impact of the disease on affected women and their families. The following report describes the concert of efforts undertaken by the medical societies to optimize national breast cancer care by organizational centralization of multidisciplinary medical competence in certified breast centers (CBC), aiming to attain continual quality of health care by implementation of evidence-and consensus-based guidelines. Centralization and the systematic pursuit of organizational development by tracking guideline adherence using performance quality indicators over time demonstrate the feasibility and practicability of the implementation concept to bridge the gap between determined scientific best evidence and applied best practice. However, the proof of concept will remain pending until the data of the population-based cancer registries are analyzed for survival estimates

Prevalence of vulvovaginal candidiasis in gynecological practices in Germany: A retrospective study of 954,186 patients

Background and Purpose: To the best of our knowledge, no information is available regarding the treatment of vulvovaginal candidiasis in gynecological practices. The goal of this study was to analyze the prevalence of vulvovaginal candidiasis (VVC) and the drugs prescribed for the treatment of this condition in women followed in gynecological practices in Germany. Materials and Methods: All the women followed in 262 gynecological practices between November 2014 and October 2016 were included in this study. The first outcome was the prevalence of patients diagnosed with VVC during this period. The second outcome was the prevalence of women with VVC who received an appropriate vaginal or systemic antimycotic prescription within 30 days after their first VVC diagnosis. Covariables included the use of gynecological/systemic antibiotics, consumption of oral/vaginal contraceptives, cancer, pregnancy, diabetes, and psychiatric diseases including depression, anxiety, and adjustment and somatoform disorders. Results: Between 2014 and 2016, 954,186 women were followed in gynecological practices, and 50,279 (5.3%) women were diagnosed with VVC during the same period. The use of gynecological antibiotics (OR=2.88), systemic antibiotics (OR=1.45), oral contraceptives (OR=1.74), and vaginal contraceptives (OR=1.84) were associated with an increase in the risk of VVC diagnosis. Cancer (OR=1.20) and pregnancy (OR=1.59) were additional risk factors. Approximately 75% of women diagnosed with VVC received an antimycotic prescription. The three most frequently prescribed drugs were clotrimazole (72%), fluconazole (14%), and nystatin (6%). Conclusion: More than 5% of women were diagnosed with VVC and the majority of them received an appropriate prescription

Vergleichende Wertung von Mikro- und Makrometastasen in axillären Sentinel- und non-Sentinel Lymphknoten bei Frauen mit Mammakarzinom

Die SLN-Biopsie hat sich als diagnostische Möglichkeit bei Patienten mit Mammakarzinom und klinisch unauffälligem Lymphknotenstatus etabliert. Mit einer zunehmend detaillierten Aufarbeitung ist es möglich, histopathologisch kleinste Lymphknotenmetastasen zu detektieren. Der Lymphknotenstatus hat einen wichtigen Stellenwert für die weitere Prognose des Krankheitsverlaufs und die Therapieplanung. Unter anderem ist er beispielsweise für die Wahl der adjuvanten Chemotherapie entscheidend. Sowohl die klinische Relevanz, als auch die prognostische Bedeutung insbesondere von sehr kleinen Metastasen im axillären SLN sind weiterhin diskussionswürdig. In der vorliegenden Disser- tation mit dem mit dem Titel „Vergleichende Wertung von Mikro- und Mak- rometastasen in axillären Sentinel- und non-Sentinel Lymphknoten bei Frauen mit Mammakarzinom“ handelt es sich um eine retrospektive Analyse von 599 Patientinnen mit Mammakarzinom, bei denen eine SLN-Biopsie durchgeführt wurde. Die detektierten Mikro- und Makrometastasen in SLN und in non-SLN wurden in ihrer Häufigkeit deskriptiv mit spezifischen Patientinnen- und Tu- morcharakteristika analysiert. Mit Hilfe dieser Daten erscheint es möglich, das Risiko für eine weitergehende Metastasierung in den axillären Lymphknoten einzugrenzen und diese Erkenntnis in das individuelle Therapiekonzept für die Patientin einzubinden. Abschließend kann festgestellt werden, dass Prognosen für das Auftreten von unterschiedlichen Größen der Metastasen in SLN existieren. Mit den ausgewer- teten Daten konnten signifikante Häufigkeiten erarbeitet werden, mit denen es möglich ist, das Risiko für eine Metastasierung besser vorherzusagen. Dabei scheinen einige der erhobenen Patientencharakteristika signifikant häufig nachweisbar. Mikrometastasen lassen sich signifikant häufiger bei den Patien- tinnen in der jüngeren Altersgruppe von 36 bis 49 Jahren nachweisen. Zeigt sich ein erhöhtes Vorliegen von Östrogenrezeptoren, treten signifikant häufiger SLN mic auf. Im Stadium GII des Primärtumors besteht ein signifikant hohes Risiko für SLN mic.Außerdem findet sich ein signifikant hohes Risiko für SLN mic im Stadium T1b des Primärtumors. Das Auftreten von Mikrometastasen im SLN nimmt bis zum Stadium T1c des Primarius zu, es wird jedoch dann, bei weiterer Größenzu- nahme des Primärtumors, durch das erhöhte Vorkommen von Makrometasta- sen abgelöst. Dies kann durch ein signifikant erhöhtes Auftreten für SLN mak im Stadium T2 des Primärtumors übereinstimmend bestätigt werden. Abschließend kann festgehalten werden, dass GII und lobuläre Primärtumore rein statistisch die höchste Wahrscheinlichkeit für Mikrometastasen haben. GI und GII differenzierte Tumore zeigen eher Mikrometastasen als GIII Tumore und diese eher eine Makrometastasierung. Je größer die Metastasen im SLN sind, desto höher ist das Risiko für weitere Metastasen in der SAD. Mit einer 17 prozentigen Metastasierungswahrscheinlichkeit nach SLN mic gegenüber einer 46,8 prozentigen Metastasierungswahrscheinlichkeit nach SLN mak ist das Risiko für weitere Metastasen nach Makrometastasen im SLN signifikant erhöht. Dieses Ergebnis stimmt mit den aktuellen Therapieleitlinien überein

The adherence paradox : guideline deviations contribute to the increased 5-year survival of breast cancer patients

Background: In German breast cancer care, the S1-guidelines of the 1990s were substituted by national S3-guidelines in 2003. The application of guidelines became mandatory for certified breast cancer centers. The aim of the study was to assess guideline adherence according to time intervals and its impact on survival. Methods: Women with primary breast cancer treated in three rural hospitals of one German geographical district were included. A cohort study design encompassed women from 1996–97 (N = 389) and from 2003–04 (N = 488). Quality indicators were defined along inpatient therapy sequences for each time interval and distinguished as guideline-adherent and guideline-divergent medical decisions. Based on all of the quality indicators, a binary overall adherence index was defined and served as a group indicator in multivariate Cox-regression models. A corrected group analysis estimated adjusted 5-year survival curves. Results: From a total of 877 patients, 743 (85 %) and 504 (58 %) were included to assess 104 developed quality indicators and the resuming binary overall adherence index. The latter significantly increased from 13–15 % (1996–97) up to 33–35 % (2003–04). Within each time interval, no significant survival differences of guideline-adherent and -divergent treated patients were detected. Across time intervals and within the group of guideline-adherent treated patients only, survival increased but did not significantly differ between time intervals. Across time intervals and within the group of guideline-divergent treated patients only, survival increased and significantly differed between time intervals. Conclusions: Infrastructural efforts contributed to the increase of process quality of the examined certified breast cancer center. Paradoxically, a systematic impact on 5-year survival has been observed for patients treated divergently from the guideline recommendations. This is an indicator for the appropriate application of guidelines. A maximization of guideline-based decisions instead of the ubiquitous demand of guideline adherence maximization is advocated

Impact of the COVID-19 Pandemic on Gyne-Oncological Treatment—A Retrospective Single-Center Analysis of a German University Hospital with 30,525 Patients

The study pursues the objective of drawing a comparison between the data of gyne-oncology, gynecology, and obstetrics patient collectives of a German university hospital regarding the progression of patient number and corresponding treatment data during the five-year period of 2017–2021 to assess the impact of the COVID-19 pandemic on gyne-oncological treatment. Descriptive assessment is based on data extracted from the database of the hospital controlling system QlikView® for patients hospitalized at the Department of Gynecology and Obstetrics of Marburg University Hospital. Gynecology and gyne-oncology experience a maintained decline in patient number (nGynecology: −6% 2019 to 2020, −5% 2019 to 2021; nGyne-Oncology: −6% 2019 to 2020, −2% 2019 to 2021) with varying effects on the specific gyne-oncological main diagnoses. Treatment parameters remain unchanged in relative assessment, but as gyne-oncology constitutes the dominating revenue contributor in gynecology (35.1% of patients, 52.9% of revenue, 2021), the extent of the decrease in total revenue (−18%, 2019 to 2020, −14%, 2019 to 2021) surpasses the decline in patient number. The study displays a negative impact on the gynecology care situation of a German university hospital for the entire pandemic, with an even greater extent on gyne-oncology. This development not only endangers the quality of medical service provision but collaterally pressurizes gynecology service providers