Epidemiology of haemophagocytic lymphohistiocytosis at the population level in Germany

Left atrial appendage occlusion: trends in demographics and in-hospital outcomes-a German nationwide analysis

BACKGROUND

LAAO is an interventional, prophylactic treatment to prevent cardioembolic stroke in patients with non-valvular atrial fibrillation.

AIMS

The aim of this study was to assess gender differences and age-related in-hospital course of all patients undergoing left atrial appendage occlusion (LAAO) in Germany.

METHODS

The Research Data Center of the Federal Statistical Office accessed interrogation of its Diagnosis Related Groups (DRG) statistics database. In a retrospective observational manner, all German in-hospital cases from 2016 to 2022 with a coded LAAO procedure were analyzed.

RESULTS

LAAO was performed on a total of 40,435 patients, 39.2% of whom were female. The relative frequency of procedures in the German male population over the age of 60 was twice as high as in the German female population. The median age was 78 (IQR: 72-82) years. Compared to 28.3% in 2016, in 2022 40.1% of all patients were over 80 years of age (increased by 152%). Cases of patients over 85 years of age increased from 7.7 to 11.4% during the same time period. We found an in-hospital death rate for patients < 70, 70-75, 80-85 and > 85 years of age of 0.8, 1.0, 1.4 and 2.2% respectively. Further, we saw significantly higher MACE rates (< 75 years: 4%, 75-85 years: 5%, > 85 years: 7%) in patients with a higher age. Gender was not significantly associated with a higher rate of in-hospital mortality.

CONCLUSIONS

In Germany, LAAO is increasingly performed in older patients with a strong gender imbalance. Age was independently associated with higher in-hospital MACE and mortality rates. This data provides a further basis to balance risks and benefits of LAAO as a preventive procedure and highlights the need for further prospective studies.

Lymphoma-associated hemophagocytic lymphohistiocytosis (LA-HLH): a scoping review unveils clinical and diagnostic patterns of a lymphoma subgroup with poor prognosis

Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome driven by pathologic activation of cytotoxic T-lymphocytes and macrophages. Despite advances in diagnostics and management, adult patients with lymphoma-associated HLH (LA-HLH) harbor particularly poor prognosis and optimal treatment remains challenging. As systematic data on LA-HLH are scarce, we aimed to synthesize research evidence by thorough analysis of the published literature in PubMed (MEDLINE-database) within the context of a scoping review. Of 595 search results, 132 articles providing information on 542 patients were reviewed and analyzed. Median patient age was 60 years (range, 18-98) with male predominance (62.7%). B- and T-NHL were equally represented (45.6% and 45.2%), Hodgkin's lymphoma was reported in 8.9% of the cases. The majority of patients (91.6%) presented in Ann-Arbor-Stages III and IV, and bone marrow infiltration was observed in a significant proportion of patients (61.5%). Soluble CD25 levels were markedly elevated (median 10,000 U/ml), with levels beyond 10,000 U/ml indicating unfavorable prognosis for 30-day and overall survival. 66.8% of the patients died after median 5.1 months. LA-HLH remains a clinical challenge requiring specialized management. Timely diagnosis and appropriate lymphoma-specific treatment are of utmost importance to enhance patient outcomes.

[Diagnostics and treatment of hemophagocytic lymphohistiocytosis]

Hemophagocytic lymphohistiocytosis (HLH) is a hyperferritinemic hyperinflammatory syndrome. A primary hereditary form can be distinguished from a secondary acquired form. In adults the secondary form accounts for the vast majority of cases. Infections, malignancies and autoimmune disorders are common triggering factors of secondary HLH. Persistent fever, bicytopenia or pancytopenia and splenomegaly represent major symptoms in HLH and occur in virtually all patients. The diagnosis of HLH is made on the basis of the HLH-2004 criteria. The probability of the presence of HLH can be estimated using the HScore. Patients with HLH require immunosuppressive treatment. Hence, high doses of corticosteroids represent the cornerstone of treatment. Furthermore, immunoglobulins, anakinra, ruxolitinib or etoposide are given depending on the triggering factor. The course and prognosis of HLH are dependent on the early initiation of treatment, the triggering factor and the response to treatment.

[Treatment of hemophagocytic lymphohistiocytosis in patients in the intensive care unit]

Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterized by hyperferritinemia. A differentiation is made between hereditary and acquired forms. In contrast to children, almost all cases in adult patients consist of acquired secondary HLH. Infections, malignancies and autoimmune diseases are frequent triggers of secondary HLH. More recently, cases of HLH have also been described in association with immunotherapy, e.g., when using chimeric antigen receptor (CAR) T‑cell treatment. In critically ill patients in the intensive care unit (ICU), sepsis represents the major differential diagnosis of HLH due to the frequently similar clinical presentation. Sometimes both sepsis and HLH are present at the same time. An early diagnosis and timely initiation of immunosuppressive treatment are essential for the further course and prognosis of HLH. Therefore, HLH should be considered as a possible diagnosis in critically ill patients with persistent fever and additional compatible symptoms (e.g., splenomegaly, neurological symptoms) or laboratory parameters (e.g., hyperferritinemia, cytopenia of two or three cell lines, increased transaminases). The diagnosis of HLH is made on the basis of the HLH-2004 criteria. The HScore can be used to estimate the probability of the presence of HLH. Corticosteroids given at high doses are the cornerstone of HLH treatment. Furthermore, immunoglobulins, etoposide, anakinra or ruxolitinib can complement treatment depending on the HLH trigger. The course of HLH depends on the timely initiation of treatment, the underlying trigger and the response to treatment. Despite progress in terms of diagnostics and targeted treatment, the prognosis of critically ill HLH patients is still poor.