[Tryptophan immunoadsorption for multiple sclerosis and neuromyelitis optica: therapy option for acute relapses during pregnancy and breastfeeding]

BACKGROUND

Approximately 25 % of women with multiple sclerosis (MS) suffer clinically relevant relapses during pregnancy. Almost all disease-modifying drugs are contraindicated in pregnancy. High-dose glucocorticoids have some serious risks, especially within the first trimester. Tryptophan immunoadsorption (IA) provides a safe option to treat MS relapses during pregnancy.

OBJECTIVES

In this case series we describe for the first time the use of tryptophan IA for MS and neuromyelitis optica (NMO) relapses during pregnancy and breastfeeding.

PATIENTS AND METHODS

In this study a total of 9 patients were retrospectively analyzed of which 7 patients received IA treatment during pregnancy, 2 during breastfeeding and 4-6 tryptophan IA treatments were performed per patient with the single use tryptophan adsorber. Primary outcome was symptom improvement of the relapse.

RESULTS

In this study four patients with MS and one with NMO relapse during pregnancy were treated with IA without preceding glucocorticoid pulse therapy. The MS patients showed improvement in the expanded disability status scale (EDSS) by at least one point, the NMO patient showed significant improvement in visual acuity and two pregnant patients with steroid-refractory relapses showed clinically relevant improvement after IA. Of the patients two suffered from steroid-refractory relapses during breastfeeding and relapse symptoms improved in both cases after treatment with IA. All treatments were well tolerated and no serious adverse events occurred.

CONCLUSION

Tryptophan IA was found to be safe, well-tolerated and effective in the treatment of MS and NMO relapses during pregnancy and breastfeeding, sometimes without preceding glucocorticoid pulse therapy. A binding recommendation is limited without prospective clinical studies.

[Benzodiazepine hypnotics, zolpidem and zopiclone on private prescriptions: use between 1993 and 2012]

OBJECTIVE

Previous analyses showed that benzodiazepine hypnotics as well as zolpidem and zopiclone (Z drugs) were increasingly being dispensed on so-called private prescriptions (Privatverordnungen) in Germany. Any doctor can provide private prescriptions for prescription drugs which are fully funded by the patient. This study aimed to analyze the amount of private prescriptions for hypnotics over the last 20 years.

METHODS

We compared utilization data from statutory health insurance claims with purchasing statistics from community pharmacies for the years 1993-2012.

RESULTS

From 1993 to 2012 purchased packages of hypnotics decreased (from 14.9 to 9.9 million). Benzodiazepines were dispensed less and Z drugs more often. In 2012 zopiclone (4.3 million packages of which 42.7 % were private prescriptions), zolpidem (3.6 million, 57.6 %) and lormetazepam (0.8 million, 57.8 %) were most often prescribed.

CONCLUSION

Trends in prescribing Z drugs are particularly noticeable whereby zolpidem was dispensed more often on private prescriptions than zopiclone. This seems to be further evidence for a higher dependence and abuse potential of zolpidem.

[Pediatric emergencies in the emergency medical service]

Out-of-hospital pediatric emergencies occur rarely but are feared among medical personnel. The particular characteristics of pediatric cases, especially the unaccustomed anatomy of the child as well as the necessity to adapt the drug doses to the little patient's body weight, produce high cognitive and emotional pressure. In an emergency standardized algorithms can facilitate a structured diagnostic and therapeutic approach. The aim of this article is to provide standardized procedures for the most common pediatric emergencies. In Germany, respiratory problems, seizures and analgesia due to trauma represent the most common emergency responses. This article provides a practical approach concerning the diagnostics and therapy of emergencies involving children.

[Resistance testing for urinary tract infections. A barrier to guideline implementation]

BACKGROUND

Urinary tract infections (UTI) are among the most common reasons for antibiotic prescriptions. Due to increasing resistance rates, antibiotic therapy should be targeted and based on evidence-based recommendations. Test results and recommendations by medical laboratories have a relevant impact on the choice of antibiotics. The extent to which medical laboratories consider antibiotics recommended by evidence-based treatment guidelines in microbiological testing is unclear.

OBJECTIVES

The aim of the present study is to assess whether guideline recommendations for antibiotic therapy of UTI are taken into account by medical laboratories in northern Germany.

MATERIALS AND METHODS

A standardized and piloted questionnaire was used in our telephone survey. All microbiological laboratories in northern Germany (Hamburg, Bremen, Lower Saxony, Schleswig-Holstein, and Mecklenburg-Western Pomerania; n = 82) were asked about their standards in diagnosing and microbiological testing of urine cultures.

RESULTS

A total of 71 of the 82 contacted laboratories perform microbiological tests, whereby 40 of these participated (56 %). Most of the laboratories (43 %) routinely perform microbiological testing when bacterial counts were ≥ 10(4) colony forming units per ml (CFU/ml), 15 % ≥ 10(5) CFU/ml, 17 % ≥ 10(3) CFU/ml, and 8 % ≥ 10(2) CFU/ml. Antibiotic testing includes ciprofloxacin (95 %), cotrimoxazole (87.5 %), trimethoprim (57 %), fosfomycin (85 %), and nitrofurantoin (72 %).

CONCLUSIONS

The diagnostic threshold recommended in evidence-based guidelines (10(3) CFU/ml) is used only by a few laboratories. Antibiotics recommended as a first line therapy are only partly taken into account in microbiological testing. This variance in different diagnostic thresholds and microbiological testing is a barrier to guideline implementation.

Improving postoperative pain management in children by providing regular training and an updated pain therapy concept

BACKGROUND

In recent years, children's hospitals have increasingly implemented postoperative pain management protocols to reduce postoperative pain and improve patient satisfaction. The effectiveness and long-term sustainability of such protocols have rarely been studied. Therefore, we conducted a prospective intervention study to assess the impact of regular training and improvement of clinical processes on the quality of postoperative pain management.

METHODS

We conducted an initial assessment of the status quo of postoperative pain management (Audit 1) followed by repeated training and improvement of clinical processes (analgesic pocket card, parents' brochure, modification of the patient chart, bimonthly advanced trainings sessions) and a follow-up review after 3 years (Audit 2). We used a data entry form, a patient survey, and an anonymous questionnaire for the nursing staff as measurement tools.

RESULTS

Our analysis included a total of 93 and 85 patients in the initial and final audits. The return rates of the nursing staff questionnaire were 83% (Audit 1) and 77% (Audit 2). The training and process improvements resulted in significant improvement in the administration of analgesics for pain requiring treatment, the control of pain measurement after the administration of analgesics and the use of non-pharmacological pain therapies. The patients reported faster administration of analgesics for acute pain and improved pain relief following the intervention.

CONCLUSIONS

Repeated training and improvement of clinical processes can significantly improve the long-term quality of postoperative pain management in children with a tolerable amount of effort on the part of health care professionals and institutions.

Underuse of proton-pump inhibitors in older patients newly starting NSAID treatment

OBJECTIVE

Proton pump inhibitors (PPIs) are recommended for the prevention of traditional non-steroidal anti-inflammatory drugs (tNSAIDs)-related ulcer complications in high-risk patients. We aimed to study to which extent older persons initiating tNSAIDs with and without oral corticosteroids receive PPIs and whether sex and age influence treatment.

METHODS

We analysed claims data of the German health insurance company BARMER GEK, covering about 9 million persons. A cohort of new users of tNSAIDs aged 65 years and older starting treatment from 1 January 2011, through 1 December 2012 was included. Concurrent use of oral corticosteroids was assessed within the 28 days before the index date. Persons were categorised as users of PPIs if they filled a prescription within 28 days before or after the index prescription.

RESULTS

A total of 83,326 persons met the inclusion criteria (64.1% females; mean age: 74.7 years). Of these new users of tNSAID, 27.8% received PPIs within 28 days before or after the index date (females: 29.4% and males: 25.0%). Of the 2857 persons with concurrent prescriptions of oral corticosteroids, 42.8% also received PPIs (females: 43.4% and males: 41.8%). An increase in prescribing of PPIs with age was found in all new users as well as in those concurrently receiving oral corticosteroids.

CONCLUSIONS

We found that gastroprotective agents are not prescribed to older new users of tNSAIDs as recommended. When compared with earlier studies, adherence to guidelines still remains low.

[Typical problems in pediatric emergencies: Possible solutions]

BACKGROUND

Pediatric emergencies are rare and challenging for health care providers, parents, and patients. The purpose of this article is to highlight typical difficulties in the treatment of pediatric patients and to discuss potential solutions.

MATERIALS AND METHODS

This article is based on a selective literature search using PubMed and the experience of the authors in the field of simulation and pediatric emergencies.

RESULTS

Inexperience with pediatric emergencies, uncertainty in technical skills, in the usage of pediatric equipment and in medication dosage as well as parental presence foster the perception of stress and potentially compromise the success of patient care. Beside implementation of simplified technical skill devices (e.g., intraosseous vascular access system, supraglottic airway devices, and alternative approaches for drug administration), there have been many efforts in recent years to improve patient safety. Tools for estimating body weight and precalculated drug-dosing charts have been implemented as well as standardized courses for guidelines, technical skills, and team-related skills have been established.

CONCLUSION

To improve patient safety, regular training and implementation of a sustainable safety culture are mandatory.

Experimental data in keratophakia

With the aid of a thermistor, the temperature decrease in corneal stroma during keratophakia is measured. 1 min after the beginning of the freezing process the temperature is -15 degrees C, 1 min later it is -40 degrees C, and 4 min after the beginning of the freezing process it is -50 degrees C. This temperature course is programmed into the constant rate freezer, in which any number of tissue samples can be frozen at the same time and with a reproducible freezing curve. The preliminary results indicate that under the use of different cryoprotective agents the radioactivity after 35S incorporation is 50-70% of the non-frozen control cornea.

[Sex-specific differences in drug utilisation in different phases of life]

The aim of the present study is to analyse sex-specific differences in drug utilisation during different phases of life using relevant diseases as examples. We used a cohort of 1.7 million subjects who were insured with the Gmünder ErsatzKasse (GEK), a German health insurance fund, for at least one day in all four quarters of 2009. We analysed subjects with outpatient diagnoses of the following diseases: attention-deficit/hyperactivity disorder (ADHD) (0-17 years), hypothyroidism (18-49 years), osteoporosis (50-79 years) and coronary heart disease (80 + years). Analysis was performed on an active-substance level. A number of differences were observed in drug treatment for the selected diseases (for example, substances for ADHD were prescribed more often in males and for hypothyroidism more often in females), as well as in prescribing practices relating to other drugs used in these groups. However, clear explanations for these differences, such as drug approval status, were not always apparent.

Intravenous levetiracetam in clinical practice--Results from an independent registry

PURPOSE

Most common clinical studies with antiepileptic drugs do not reflect medical everyday practice due to their strict in- and exclusion criteria and specifications of treatment regimens. Here we present a large non-interventional registry with the intention to evaluate the spectrum of applications in daily use and the efficacy and tolerability of intravenously given levetiracetam (LEV-iv).

METHODS

In a prospective approach of 17 neurological and neuropediatric centres in Germany LEV-iv treated patients of all ages were included over a period of 10 months. The observational period was 10 days with daily documentation of LEV-iv administration, type and frequency of seizures, currently used drugs and doses, and adverse events (AEs). In addition, treatment efficacy and tolerability were assessed by patients and physicians at study end as well as practicability of LEV-iv using a five-step scale.

RESULTS

In 95 patients LEV-iv was administered, 93 were included into the analysis. The median LEV-iv dose was 1500 mg (range 110-6000 mg) per day. Median age was 66 years (range 0.7-90.3 years). The majority of patients (n=70, 75%) suffered from status epilepticus (SE, n=55, 59%) and acute seizure clusters (n=15, 16%). Of those with SE, 41 patients (75%) had SE for the first time. Acute seizure clusters and SE terminated in 83% after LEV-iv administration. A total of 29 adverse events were reported in 17 of the 95 patients from the safety set. Ten of these were at least possibly related to LEV-iv treatment. Slight decrease of blood pressure during the infusion (3 patients each) was captured most frequently. No serious side effect was observed. Physicians rated the efficacy and tolerability of LEV-iv treatment as good or very good in 78% and 82% of the cases, respectively.

CONCLUSION

In this large observational study of everyday practise the use of LEV-iv exhibited a remarkable good response and tolerability in patients with acute onset seizures (mostly SE). Further randomized controlled studies, like the established status epilepticus trial (ESET) are needed to confirm these findings.

[Differences in sociodemographic characteristics, health, and health service use of children and adolescents according to their health insurance funds]

Differences in the socioeconomic characteristics and morbidity between members of German private and statutory health insurance funds and also between several statutory health insurances have been shown for adults. We used data from the National Health Survey for Children and Adolescents (KiGGS) to study differences in sociodemographic characteristics, health risks, morbidity, and health service use in child and adolescent insurants of different types of health insurance funds (Ersatzkasse, Allgemeine Ortskrankenkasse, Betriebskrankenkasse , Innungskrankenkasse, other statutory health insurance funds, private health insurance). Differences in the proportion of respondents with a migration background, somatic diseases, psychopathological problems, and contact with a dentist between the different health insurance fund types were found. These results should be considered in studies on health inequalities, which often focus solely on differences between statutory and private health insurance. Our results are also of relevance for health services research using the claims data of health insurance funds.

Who gets dipyrone (metamizole) in Germany? Prescribing by age, sex and region

WHAT IS KNOWN AND OBJECTIVE

Metamizole (dipyrone) is an analgesic that has been the focus of considerable controversy regarding its safety. Because of potentially life-threatening blood disorders such as agranulocytosis, it has been withdrawn in many countries but not in Germany, where prescribing even increased over recent years. We aimed to evaluate prescribing of metamizole in Germany with respect to age, sex and regional variations.

METHODS

Using data of a statutory health insurance, we analysed a cohort of 1·7 million persons who were insured at least 1 day in each quarter of 2009. Outcome of interest was the outpatient prescription prevalence, for example the proportion of persons receiving at least one prescription of metamizole.

RESULTS AND DISCUSSION

A total of 6·8% received metamizole with a higher prescribing prevalence in females (7·8% vs. 6·0%). The prevalence increased with age up to 26·7% in persons ≥85 years (men: 21·1%; and women: 30·4%). We found large regional variations with higher prevalences in the northern part of Germany. Most of the prescriptions were issued by general practitioners (78·9%). 58·3% were liquid oral formulations with considerable regional variations ranging between 32·3% in Mecklenburg-West Pomerania and 67·3% in North Rhine-Westphalia. Overall, liquid oral forms are much more often prescribed in the western than in the eastern part of Germany.

WHAT IS NEW AND CONCLUSION

Metamizole - a drug with a relatively narrow indication - is often prescribed in Germany with relevant differences by age, sex and region. Qualitative studies should clarify reasons for this. Further quantitative research should investigate small-area variations, indications and treatment durations.

[Linkage of statutory health insurance data with those of a hospital information system: feasible, but also "useful"?]

AIM

Administrative data are increasingly being linked with other data sources for research purposes in the field of epidemiology and health services research abroad. In Germany, the direct linkage of routine data of statutory health insurance (SHI) providers with other data sources is complicated due to strict data protection requirements. The aim of this analysis was to evaluate an indirect linkage of SHI routine data with data of a hospital information system (HIS).

METHODS

The dataset comprised data from 2004 to 2010 from 2 sickness funds and one HIS. In both data sources, hospitalisations were restricted to admissions into one hospital with at least one diagnosis of heart failure. The 2 data sources were linked, in cases of the agreement of the admission and discharge dates, as well as the agreement of at least a certain percentage of diagnoses in HIS data when compared to SHI data (full coding depth). Based on the direct linkage using the pseudonymised insurance number as gold standard, the proposed linkage approach was evaluated by means of test statistics. Furthermore, the completeness of relevant information of the HIS was described.

RESULTS

The dataset contained 3 731 hospitalisations from the HIS and 8 172 hospitalisations from the SHI routine data. The sensitivity of the linkage approach was 86.7% in the case of an agreement of at least 30% of the diagnoses and decreased to 41.7% in the case of 100% agreement in the diagnoses. The specificity was almost 100% at all studied cut-offs of agreement. Anthropometric measures and diagnostic information were available only for a small fraction of cases in the data of the HIS, whereas information on the health status and on laboratory information was comparatively complete.

CONCLUSION

For the linkage of SHI routine data with complementary data sources, indirect linkage methods can be a valuable alternative in comparison to direct linkage, which is time-consuming with regard to planning and application. Since the proposed approach was used in a relatively small sample and a restricted patient population, a replication using nation-wide data without respective restrictions would require an extension of the algorithm. Furthermore, the large administrative effort seems questionable considering the comparatively high amount of missing values in interesting information in the HIS.

Fluorine magic: one new organofluorine linker leads to three new metal–organic frameworks

2-Fluoro-1,3,5-benzene-tricarboxylic acid (Fbtc) is used as new linker for metal–organic frameworks and leads to three MOFs UHM-31, -32 and -33.

[Increased prescribing of proton pump inhibitors in ambulatory care over the years 2005 - 2013]

BACKGROUND

In many countries, proton pump inhibitors (PPIs) are increasingly prescribed over recent years and there is evidence of overprescribing. The aim of this article was to analyse the utilization of PPIs in Germany with respect to age and sex and to study regional variations as well as differences regarding medical specialties.

METHODS

We used claims data of the BARMER GEK for the years 2005 - 2013. Main outcome was the prescribing prevalence, e. g., the proportion of persons with at least one prescription of PPIs in the corresponding year. In addition, the prescribing medical specialties and regional differences were studied for the year 2013.

RESULTS

Over the years 2005 to 2013, the prescribing prevalence increased linearly from 8.2 % to 16.2 % (+ 97 %). Females were more often affected than males. Prevalences were also increasing with age (0 - 5 years: 0.2 % to 95 + years: 39.5 % in 2013). Regional differences were comparatively low (interquartile range of the postal code regions: 15.0 - 17.0 %). General practitioners prescribed a large majority of PPIs (90.1 %) with even higher proportions in the older age (98.1 % in persons aged 95 + years).

CONCLUSIONS

The proportion of persons receiving PPIs has doubled over the past 9 years. Physicians should review their prescribing habits critically on a periodic basis.