Arrhythmias among Older Adults Receiving Comprehensive Geriatric Care: Prevalence and Associated Factors

BACKGROUND

Cardiovascular diseases and arrhythmias are medical conditions that increase with age and are associated with significant morbidities and mortality. The aim of the present study was to investigate the prevalence of arrhythmias and clinical associations in the collective of older adults receiving comprehensive geriatric care (CGC).

METHODS

Holter ECG monitoring (HECG) of older patients hospitalized for CGC was analyzed. The prevalence of arrhythmias and the associations between the presence of arrhythmias, patients' characteristics and the functional status regarding basic activities of daily living (assessed by the Barthel index (BI)), walking ability (assessed by the timed up and go test (TUG)), and balance and gait (assessed by the Tinetti balance and gait test (TBGT)) were examined.

RESULTS

In the presented study, 626 patients were included (mean age: 83.9 ± 6.6 years, 67.7% were female). The most common arrhythmias detected in HECG were premature ventricular contractions (87.2%), premature atrial contractions (71.7%), and atrial fibrillation (22.7%). Atrial flutter was found in 1.0%, paroxysmal supraventricular tachycardia in 5.8%, non-sustained ventricular tachycardia in 12.5%, first-degree AV block in 0.8%, second-degree AV block type Mobitz I in 0.8%, second-degree AV block type Mobitz II in 0.3%, pause > 2.5 s any cause in 3.5%, and pause > 3 s any cause in 1.6% of the cases. Premature atrial contractions were associated with the female sex (74.8% vs. 65.3%, p = 0.018), whereas in male patients, the following arrhythmias were more common: premature ventricular contractions (91.6% vs. 85.1%, p = 0.029), ventricular bigeminus (8.4% vs. 3.8%, p = 0.021), and non-sustained ventricular tachycardia (17.3% vs. 10.1%, p = 0.014). Atrial fibrillation detected in HECG was more frequent in patients at high risk of falls, indicated by their TBGT score ≤ 18 (24.7% vs. 12.0%, p = 0.006), and premature ventricular contractions were more common in patients unable to walk (TUG score 5) compared to those with largely independent mobility (TUG score 1 or 2) (88.0% vs. 75.0%, p = 0.023). In a logistic regression analysis, atrial fibrillation detected in HECG was identified as a risk factor for a high risk of falls (odds ratio (OR): 2.35, 95% confidence interval (CI): 1.23-4.46).

CONCLUSION

In our study, investigation of HECG of older adults hospitalized for CGC revealed that premature atrial contractions, premature ventricular contractions, and atrial fibrillation were the most common arrhythmias. Premature atrial contractions were found to be more frequent in female patients, while male patients were more prone to premature ventricular contractions. In the investigated population, atrial fibrillation emerged as a risk factor associated with a high risk of falls.

Incidences for Fractures 2017-2021: What Do We Learn from the COVID-19 Pandemic?

PURPOSE/INTRODUCTION

In the present study, we aimed to assess the long-term incidence of fractures and during the COVID-19 pandemic.

METHODS

The current cohort study included patients who had received an initial fracture diagnosis of any type documented anonymously in the Disease Analyzer database (IQVIA) between 2017 and 2021 by physicians in 941 general practices in Germany. We investigated the development of fracture incidence over this period.

RESULTS

A total of 196,211 patients had a fracture diagnosis between 2017 and 2021. The number of patients with fracture diagnosis was highest in 2019 (n = 50,084) and lowest in 2020 (n = 46,227). The mean age of patients increased from 60.8 years in 2017 to 63.3 years in 2021. Between 58% and 60% of patients were female. From 2017 to 2019, the number of fractures documented in the younger age categories remained constant. Between 2019 and 2020, an incidence decrease was documented in the younger age groups (age group 16-40 years: -17.17%; age group 41-60 years: -18.71%; age group 61-80 years: -6.43%). By contrast, a slight increase of 3.03% was identified in the age group >80 years of age. No relevant changes in fracture incidences were noted between 2020 and 2021. Incidence rates decreased for both sexes from 2019 to 2020 (female patients: -6.27%; male patients: -10.18%). In the youngest age group (16-40 years), the decrease observed in 2020 was due to lower incidences for fractures of the upper and lower extremities (-11.9%; -12.5%) and ribs (-50.0%). In the age group ≥80 years, fracture incidences increased for the upper extremity (+2.8%), lower extremity (+8.3%), and femur (+8.3%).

CONCLUSIONS

The circumstances of the pandemic reduced the incidence of fractures in younger people, probably due to reduced recreational activities, while fracture incidence increased in older people, presumably as a result of lack of support.

Changes in the Prescription of Antibiotics and Phytopharmaceuticals in Children Treated for Acute Upper and Lower Respiratory Tract Infections in Pediatric Practices in Germany in 2013, 2018, and 2022

Background: Little is known about the recent trends in antibiotic and phytopharmaceutical prescribing for acute upper (URIs) and lower respiratory tract infections (LRIs) in children and adolescents. Therefore, this study investigated changes in the prescription of antibiotics and phytopharmaceuticals in children diagnosed with acute URIs and LRIs in pediatric practices in Germany in 2013, 2018, and 2022. Methods: The present retrospective study included children aged 2-12 years diagnosed with acute URIs or LRIs in one of 180 pediatric practices in 2013, 2018, and 2022. The URIs included nasopharyngitis, sinusitis, pharyngitis, tonsillitis, laryngitis and tracheitis, and upper respiratory infections of multiple and unspecified sites, while the LRIs corresponded to bronchitis. The primary outcomes were the proportion of children being prescribed antibiotics and the proportion of those being prescribed phytopharmaceuticals. Results: A total of 120,894 children were diagnosed with acute URIs or LRIs in 2013 compared to 116,844 in 2018 and 127,821 in 2022. The prevalence of antibiotic prescription decreased for all diagnoses between 2013 and 2022. This decrease was statistically significant for both 2013-2018 and 2018-2022 for nasopharyngitis, pharyngitis, and bronchitis. Meanwhile, there was a significant increase in the use of phytopharmaceuticals for all diagnoses between 2013 and 2018. The prevalence of phytopharmaceutical prescription decreased slightly between 2018 and 2022, but this decrease was generally not statistically significant. Conclusions: The prescription of antibiotics has decreased and that of phytopharmaceuticals has increased in children diagnosed with acute URIs and LRIs in Germany over the last decade. More data are needed to corroborate these findings in other settings.

Association between Syncope and the 6-Month Incidence of Ischemic Stroke, Arrhythmia, Brain Tumor, Epilepsy, and Anxiety Disorder

OBJECTIVES

the aim of the present study is to investigate the associations between syncope and subsequent diagnoses of brain tumor, cardiac arrhythmia, stroke/transient ischemic attack (TIA), epilepsy, and anxiety disorder in a large outpatient population in Germany.

METHODS

This retrospective cohort study uses data from the Disease Analyzer database (IQVIA). Adults who received syncope diagnosis from one of 1284 general practices between January 2005 and December 2021 (index date) were included and matched (1:1) to individuals without syncope diagnosis using a propensity score based on age, sex, the number of consultations during the follow-up period (up to 6 months), and defined co-diagnoses documented within 12 months prior to and on the index date. Finally, associations between syncope and subsequent outcome diagnoses were investigated using multivariable logistic regression models.

RESULTS

Data related to 64,016 patients with and 64,016 patients without syncope (mean age 54.5 years, 56.5% female) were available. In total, 6.43% of syncope patients and 2.14% of non-syncope patients were diagnosed with one of the five outcome diagnoses within 6 months of the index date. There was a positive and significant association between syncope and incidences of ischemic stroke/TIA (OR = 2.83, 95% CI = 2.41-3.32), arrhythmia (OR = 3.81, 95% CI = 3.44-4.18), brain tumor (OR = 4.24, 95% CI = 2.50-7.19), epilepsy (OR = 5.52, 95% CI = 4.27-7.14), and anxiety disorder (OR = 1.99, 95% CI = 1.79-2.21).

CONCLUSIONS

Syncope is significantly associated with an increased risk of subsequent ischemic stroke/TIA, cardiac arrhythmia, brain tumor, epilepsy, and anxiety disorder. Nevertheless, the cumulative incidences for all five diagnoses are very low.

BMI Impact on Readmissions for Patients Undergoing Robot-Assisted Radical Prostatectomy: A Monocentric, Single-Surgeon Serial Analysis of 500 Cases

Due to more difficult intraoperative courses, elevated rates of case abortion and unfavored postoperative outcomes in obese patients, urologists tend to consider other therapeutic modalities than prostate removal in very obese patients. With the surge in robotic surgery in the last two decades, more obese patients have undergone robot-assisted radical prostatectomy (RARP).

OBJECTIVE

This current, monocentric, retrospective serial study investigates primarily the impact of obesity on readmissions and secondarily the major complications of RARP.

METHODS

Five hundred patients from one referral center who underwent RARP between April 2019 and August 2022 were included in this retrospective study. To investigate the impact of patient BMI on postoperative outcomes, we divided our cohort into two groups with a cut-off of 30 kg/m² (according to the WHO definition). Demographic and perioperative data were analyzed. Postoperative complications and readmission rates were compared between standard, normal patients (NOBMI-BMI under 30; n = 336, 67.2%) and overweight patients (OBMI-BMI equal to/more than 30; n = 164, 32.8%).

RESULTS

OBMI patients had bigger prostates on TRUS, more comorbidities and worse baseline erectile function scores. They also received fewer nerve-sparing procedures than their counterparts (p = 0.005). Analysis showed no statistically significant differences in readmission rates or in minor or major complications (p = 0.336, 0.464 and 0.316, respectively). In a univariate analysis, BMI could predict positive surgical margins (p = 0.021).

CONCLUSION

Performing RARP in obese patients seems to be safe and feasible, without major adverse events or elevated readmission rates. Obese patients should be informed preoperatively about the elevated risk of higher PSMs and technically more difficult nerve-sparing procedures.

Comprehensive Geriatric Care in Older Adults: Walking Ability after an Acute Fracture

BACKGROUND/OBJECTIVES

Comprehensive Geriatric Care (CGC) is a specific multimodal treatment for older patients. In the current study, we aimed to investigate walking performance after CGC in medically ill patients versus those with fractures.

METHODS

The timed up and go test (TuG), a 5-grade scale assessment (1 = no walking impairment to 5 = no walking ability at all) for evaluating individual walking ability was performed in all patients who underwent CGC prior to and after treatment. Factors associated with improvement in walking ability were analyzed in the subgroup of patients with fractures.

RESULTS

Out of 1263 hospitalized patients, 1099 underwent CGC (median age: 83.1 years (IQR 79.0-87.8 years); 64.1% were female). Patients with fractures (n = 300) were older than those without (n = 799), (median 85.6 versus 82.4 years, p = 0.001). Improvement in TuG after CGC was found in 54.2% of the fracture patients compared to just 45.9% of those without fractures. In fracture group patients, TuG improved from median 5 on admission to median 3 on discharge (p = 0.001). In fracture patients, improvement in walking ability was associated with higher Barthel index values on admission (median 45 (IQR: 35-55) versus 35 (IQR: 20-50): p = 0.001) and Tinetti assessment scores (median 9 (IQR: 4-14.25) versus 5 (IQR: 0-13); p = 0.001) and was negatively associated with the diagnosis of dementia (21.4% versus 31.5%; p = 0.058).

CONCLUSION

CGC improved walking ability in more than half of all patients examined. Older patients in particular might benefit from undergoing the procedure after an acute fracture. A better initial functional status favors a positive result following the treatment.

Chronic Low Back Pain and Incident Transient Ischemic Attack and Stroke in General Practices in Germany

The aim was to investigate the association between chronic low back pain (CLBP) and incident transient ischemic attack (TIA) and stroke in Germany. The present retrospective cohort study included adults aged ≥18 years who were diagnosed for the first time with CLBP in one of 1198 general practices in Germany in 2005-2019 (index date). Patients without CLBP were matched to those with CLBP (1:1) using a propensity score based on age, sex, the index year, the number of medical consultations per year during the follow-up, and the number of years of follow-up. In patients without CLBP, the index date was a randomly selected visit date. Both groups were followed for up to 10 years. There were 159,440 patients included in the study (mean (SD) age: 52.1 (16.5) years; 51.5% women). Within 10 years of the index date, 6.5% and 5.9% of patients with and without CLBP were diagnosed with TIA or stroke, respectively (log-rank p-value < 0.001). The Cox regression analysis corroborated these results, as there was a significant association between CLBP and incident TIA or stroke (HR = 1.28, 95% CI = 1.22-1.35). CLBP was positively and significantly associated with incident TIA and stroke in Germany. More research is warranted to better understand this relationship.

The COVID-19 Pandemic Enhanced the Decade-Long Trend of the Decreasing Utilization of Antibiotics

PURPOSE/INTRODUCTION

A decline in antibiotic (AB) prescriptions was reported during the coronavirus 2019 (COVID-19) pandemic. Therefore, we investigated AB utilization during the COVID-19 pandemic using data from a large database in Germany.

METHODS

AB prescriptions in the Disease Analyzer database (IQVIA) were analyzed for each year between 2011 and 2021. Descriptive statistics were used to assess developments in relation to age group, sex, and antibacterial substances. Infection incidence rates were also investigated.

RESULTS

In total, 1,165,642 patients received antibiotic prescriptions during the entire study period (mean age: 51.8; SD: 18.4 years; 55.3% females). AB prescriptions started to decline in 2015 (505 patients per practice), and this development persisted until 2021 (2020: 300 patients per practice and 2021: 266 patients per practice). The sharpest drop was observed in 2020 and occurred in both women and men (27.4% and 30.1%). In the youngest age group (≤30), the decrease was -56%, while in the age group >70, it was -38%. The number of patients with prescriptions for fluoroquinolones dropped the most, falling from 117 in 2015 to 35 in 2021 (-70%), followed by macrolides (-56%) and tetracyclines (-56%). In 2021, 46% fewer patients were diagnosed with acute lower respiratory infections, 19% fewer with chronic lower respiratory diseases, and just 10% fewer with diseases of the urinary system.

CONCLUSION

AB prescriptions decreased more in the first year (2020) of the COVID-19 pandemic than infectious diseases did. While the factor of older age influenced this trend negatively, it remained unaffected by the factor of sex and the selected antibacterial substance.

Microembolizations in the Arterial Cerebral Circulation in Patients with Atrial Fibrillation Ablation Using the Cryoballoon Technique-Protocol and Methodology of a Prospective Observational Study

There is considerable uncertainty regarding the impact of microembolic signals (MESs) on neuropsychological abilities in patients receiving pulmonary vein isolation and beyond using the cryoballoon technique. We conducted the largest prospective observational study on this topic, providing insights into the gradual unmasking of procedure-related MESs and their impacts on neuropsychological outcomes. MESs were continuously detected periprocedurally using transcranial Doppler ultrasonography. Neuropsychological status was evaluated comprehensively using the CERAD Plus test battery, which consists of 11 neuropsychological subtests. Patients with atrial fibrillation were included in the study with an equal distribution (50:50) of paroxysmal or persistent presentations. Of 167 consecutive eligible patients, 100 were included within the study enrollment period from February 2021 to August 2022. The study, including the documentation of all follow-up visits, ended in November 2022. This paper focuses on describing the study protocol and methodology and presenting the baseline data.

Effect of Neoadjuvant Hormonal Therapy on the Postoperative Course for Patients Undergoing Robot-Assisted Radical Prostatectomy

OBJECTIVES

Neoadjuvant hormonal therapy (NHT) preceding robot-assisted radical prostatectomy (RARP) may be beneficial in high-risk cases to facilitate surgical resection. Yet, its improvement in local tumor control is not obvious. Its benefit regarding overall cancer survival is also not evident, and it may worsen sexual and hormonal functions. This study explores the effect of NHT on the perioperative course after RARP.

METHODS

In this study, 500 patients from a tertiary referral center who underwent RARP by a specialized surgeon were retrospectively included. Patients were divided into two groups: the NHT (n = 55, 11%) group, which included patients who received NHT (median: 1 month prior to RARP), and the standard non-NHT (NNHT) group (n = 445, 89%). Demographic and perioperative data were analyzed. Postoperative results, complications, and readmission rates were compared between the groups.

RESULTS

NHT patients were heterogeneous from the rest regarding cancer parameters such as PSA (25 vs. 7.8 ng/mL) and tumor risk stratification, and they were more comorbid (p = 0.006 for the ASA score). They also received fewer nerve-sparing procedures (14.5% vs. 80.4%), while the operation time was similar. Positive surgical margins (PSM) (21.8% vs. 5.4%) and positive lymph nodes (PLN) (56.4% vs. 12.7%) were significantly higher in the NHT group compared to the non-NHT (NNHT) group. Hospital stay was equal, whereas catheter days were 3 days longer in the NHT group. NHT patients also suffered more minor vesicourethral-anastomosis-related complications. Major complications (p = 0.825) and readmissions (p = 0.070) did not differ between groups.

CONCLUSION

Patients receiving NHT before RARP did not experience more major complications or readmissions within 90 days after surgery. Patients with unfavorable, high-risk tumors may benefit from NHT since it facilitates surgical resection. Randomized controlled trials are necessary to measure the advantages and disadvantages of NHT.

Prostate Volume Influence on Postoperative Outcomes for Patients Undergoing RARP: A Monocentric Serial Analysis of 500 Cases

Elevated prostate volume is considered to negatively influence postoperative outcomes after robot-assisted radical prostatectomy (RARP). We aim to investigate the influence of prostate volume on readmissions and complications after RARP. Methods: A total of 500 consecutive patients who underwent RARP between April 2019 and August 2022 were included. Patients were dichotomized into two groups using a prostate volume cut-off of 50 mL (small and normal prostate (SNP) n = 314, 62.8%; large prostate n = 186, 37.2%). Demographic, baseline, and perioperative data were analyzed. The postoperative complications and readmission rates within 90 days after RARP were compared between groups. A univariate linear analysis was performed to investigate the association between prostate volume and other relevant outcomes. Results: Patients with larger prostates had a higher IPSS score, and therefore, more relevant LUTS at the baseline. They had higher ASA scores (p = 0.015). They also had more catheter days (mean 6.6 days for SNP vs. 7.5 days for LP) (p = 0.041). All oncological outcomes were similar between the groups. Although statistical analysis showed no significant difference between the groups (p = 0.062), a trend for minor complications in patients with larger prostates, n = 37/186 (19.8%) for the LP group vs. n = 37/314 (11.7%) in the SNP group, was observed. Namely, acute urinary retention and secondary anastomosis insufficiency. Major complications with an SNP (4.4%) and LP (3.7%) (p = 0.708) and readmissions with an SNP (6.25%) and LP (4.2%) (p = 0.814) were infrequent and distributed equally between the groups. In univariate analysis, prostate volume could solely predict a longer console time (p = 0.005). Conclusions: A higher prostate volume appears to have minimal influence on the perioperative course after RARP. It can prolong catheter days and increase the incidence of minor complications such as acute urinary retention. However, it might predict minor changes in operating time. Yet, prostate volume has less influence on major complications, readmissions, or oncological results.

Comprehensive Geriatric Care in Older Hospitalized Patients with Depressive Symptoms

BACKGROUND/OBJECTIVES

Depressive symptoms (DS) may interfere with comprehensive geriatric care (CGC), the specific multimodal treatment for older patients. In view of this, the aim of the current study was to investigate the extent to which DS occur in older hospitalized patients scheduled for CGC and to analyze the associated factors. Furthermore, we aimed to investigate whether DS are relevant with respect to outcomes after CGC.

METHODS

For this retrospective study, all patients fulfilling the inclusion criteria were selected by reviewing case files. The main inclusion criterion was the completion of CGC within the defined period (May 2018 and May 2019) in the geriatrics department of the Diakonie Hospital Jung-Stilling Siegen (Germany). The Geriatric Depression Scale was used to asses DS in older adults scheduled for CGC (0-5, no evidence of DS; 6-15 points, DS). Scores for functional assessments (Timed Up and Go test (TuG), Barthel Index, and Tinetti Gait and Balance test) were compared prior to versus after CGC. Factors associated with the presence of DS were studied.

RESULTS

Out of the 1263 patients available for inclusion in this study, 1092 were selected for the analysis (median age: 83.1 years (IQR 79.1-87.7 years); 64.1% were female). DS (GDS > 5) were found in 302 patients (27.7%). The proportion of female patients was higher in the subgroup of patients with DS (85.5% versus 76.3%, p = 0.024). Lower rates of patients diagnosed with chronic pulmonary obstructive disease were detected in the subgroup of patients without DS (8.0% versus 14.9%, p = 0.001). Higher rates of dizziness were observed in patients with DS than in those without (9.9% versus 6.2%, p = 0.037). After CGC, TuG scores improved from a median of 4 to 3 (p < 0.001) and Barthel Index scores improved from a median of 45 to 55 (p < 0.001) after CGC in both patients with and without DS. In patients with DS, the Tinetti score improved from a median of 10 (IQR: 4.75-14.25) prior to CGC to 14 (IQR 8-19) after CGC (p < 0.001). In patients without DS, the Tinetti score improved from a median of 12 (IQR: 6-7) prior to CGC to 15 (IQR 2-20) after CGC (p < 0.001).

CONCLUSIONS

DS were detected in 27.7% of the patients selected for CGC. Although patients with DS had a poorer baseline status, we detected no difference in the degree of improvement in both groups, indicating that the performance of CGC is unaffected by the presence of DS prior to the procedure.

Persistence with first-line antihypertensive therapy in Germany: A retrospective cohort study with 2,801,469 patients

BACKGROUND

The goal of this retrospective cohort study was to investigate 3-year persistence with antihypertensive drug therapy and the association between antihypertensive drug classes and therapy discontinuation risk in Germany.

MATERIALS AND METHODS

The present retrospective cohort study was based on the IQVIA longitudinal prescription database (LRx) and included adult outpatients (≥ 18 years) with an initial prescription of antihypertensive monotherapy alone including diuretics (DIU), β-blockers (BB), calcium channel blockers (CCB), ACE inhibitors (ACEi), and angiotensin II receptor blockers (ARB) in Germany between January 2017 and December 2019 (index date). A Cox proportional hazards regression model was also used to assess the relationship between antihypertensive drug classes and non-persistence adjusted for age and sex.

RESULTS

This study included 2,801,469 patients. Patients on ARB monotherapy exhibited the highest persistence within 1 year (39.4%) and 3 years (21.7%) after the index date. Patients on DIU monotherapy showed the lowest persistence (16.5% after 1 year, 6.2% 3 years after the index date). In the overall population, initial monotherapy with DIU (HR: 1.48) was positively associated with monotherapy discontinuation, whereas ARB monotherapy was (HR = 0.74) negatively associated with monotherapy discontinuation compared to BB. However, in the age group > 80, there was a slight negative association between DIU intake and monotherapy discontinuation (HR = 0.91).

CONCLUSION

This large cohort study reveals significant differences in 3-year persistence with antihypertensives, which were strongest for ARB and weakest for DIU. However, the differences also depended on age, with much better DIU persistence in the elderly.

Hypertensive Blood Pressure and Its Impact on Functional Outcomes among Older Adults Receiving Comprehensive Geriatric Care

BACKGROUND

Comprehensive geriatric care (CGC) is a multiprofessional treatment for older people which considers medical conditions and functional status. The aim of the presented study is to investigate the impact of hypertensive blood pressure (BP) on functional outcomes among older adults receiving CGC.

METHODS

Functional status was documented by the Barthel index (BI), Tinetti test (TBGT), and timed up and go test (TUG) prior to and after CGC. The results were analyzed in relation to hypertensive BP, indicated by mean BP ≥ 130/80 mmHg determined by 24 h blood pressure monitoring (BPM) while hospitalized.

RESULTS

In the presented monocentric, retrospective, observational study, 490 patients were included (mean age (SD): 83.86 ± 6.17 years, 72.2% females). Hypertension in BPM was found in 302 (61.6%) individuals. Hypertensive BP was associated with the female sex (p < 0.001) and current fracture (p = 0.001), and inversely associated with heart failure (p < 0.001), coronary heart disease (p < 0.001), atrial fibrillation (p < 0.001), urinary tract infection (p = 0.022), and hypocalcemia (p = 0.014). After CGC, improvements in BI (p < 0.001), TBGT (p < 0.001), and TUG (p < 0.001) were observed in patients with both normotensive and hypertensive BP profiles. The proportion of patients with outcome improvements did not differ between the two groups (BI: 84.4% vs. 88.3%, p = 0.285; TBGT: 81.1% vs. 77.7%, p = 0.357; TUG: 50.3% vs. 48.4%, p = 0.711).

CONCLUSION

Patients both with and without hypertensive BP profiles benefited from comprehensive geriatric care with comparable outcome improvements. Particularly, normotensive BP was associated with chronic cardiovascular comorbidities, indicating increased awareness of the importance of BP management in patients diagnosed with cardiac diseases.

Prevalence of Upper Respiratory Tract Infections Before, During, and After the COVID-19 Pandemic in Germany: A Cross-Sectional Study of 2 167 453 Outpatients

BACKGROUND

Although the burden of the COVID-19 pandemic on global healthcare systems is declining, long-term sequelae such as long COVID syndrome and other disease dynamics not primarily associated with COVID-19 remain a challenge. Recent data suggest that the incidence of non-COVID upper respiratory tract infections (URTI) is increasing sharply in the post-pandemic period, but there is a lack of real-world data from Germany in this respect.

METHODS

This cross-sectional study evaluated the number of patients with a diagnosis of URTI from the Disease Analyzer database (IQVIA) between January 2019 and December 2022. The number of UTRI diagnoses per practice and the duration of sick leave per patient were compared over time.

RESULTS

A total of 1 872 935 individuals (1 403 907 patients from general practices (GP) and 469 028 patients from pediatric offices) were included, 48% of whom were female. The number of URTI patients per practice was significantly higher in 2022 than in 2019 (732 vs 464, 58%, P < .001), and this was observed for both women (56%, P < .001) and men (60%, P < .001). The post-pandemic increase in the number of URTI diagnoses correlated with age and was highest in the age group between 18 and 30 years (22%, P < .001) and lowest in older patients >70 years (3%). In pediatric patients (<18 years), the increase was highest in the age group ≤5 years (89%). Both the number of patients per practice on sick leave due to URTI (184 vs 92) and the average duration of sick leave (+2 days) increased from 2019 to 2022.

CONCLUSION

Our data suggest a dramatic increase in the incidence of URTI among all demographic subgroups in Germany between 2019 and 2022, which was associated with a tremendous impact on socioeconomic variables such as the frequency or duration of sick leave. These data could be of great importance in current pandemic management and the management of future pandemics.

Dysbiosis: A Potential Precursor to the Development of a Depressive Disorder

Background: Although previous investigations have indicated that gastrointestinal pathologies facilitate the occurrence of mood disorders, there is a lack of studies based on data from clinical practice. The aim of this study was to investigate the incidence of depression in patients with dysbiosis. Methods: Adult patients (≥18 years) from 1193 general practices in Germany between January 2005 and December 2018 with an initial diagnosis of dysbiosis documented anonymously in the Disease Analyzer database (IQVIA) were analyzed. The incidence of depression diagnoses as a function of dysbiosis was calculated and multivariate regression models were applied. Results: This study included 552 patients with and 552 patients without dysbiosis. Within five years of the index date, 20.5% of patients with dysbiosis and 5.5% of individuals without dysbiosis had been diagnosed with depression (p < 0.001). Dysbiosis was found to be significantly associated with the incidence of depression (HR: 2.85 (95% CI: 2.00−4.04)). This association was slightly stronger in men (HR: 3.54) than in women (HR: 2.61) and was more pronounced in the age group >60 years (HR: 4.43). Conclusions: We identified dysbiosis as a risk factor for developing depression within 5 years after the index date. This risk seems to be higher in male than in female patients.

Obesity and lipid metabolism disorders determine the risk for development of long COVID syndrome: a cross-sectional study from 50,402 COVID-19 patients

Purpose

Metabolic disorders have been identified as major risk factors for severe acute courses of COVID-19. With decreasing numbers of infections in many countries, the long COVID syndrome (LCS) represents the next major challenge in pandemic management, warranting the precise definition of risk factors for LCS development.

Methods

We identified 50,402 COVID-19 patients in the Disease Analyzer database (IQVIA) featuring data from 1056 general practices in Germany. Multivariate logistic regression analysis was used to identify risk factors for the development of LCS.

Results

Of the 50,402 COVID-19 patients included into this analysis, 1,708 (3.4%) were diagnosed with LCS. In a multivariate regression analysis, we identified lipid metabolism disorders (OR 1.46, 95% CI 1.28–1.65, p < 0.001) and obesity (OR 1.25, 95% CI 1.08–1.44, p = 0.003) as strong risk factors for the development of LCS. Besides these metabolic factors, patients’ age between 46 and 60 years (compared to age ≤ 30, (OR 1.81 95% CI 1.54–2.13, p < 0.001), female sex (OR 1.33, 95% CI 1.20–1.47, p < 0.001) as well as pre-existing asthma (OR 1.67, 95% CI 1.39–2.00, p < 0.001) and depression (OR 1.27, 95% CI 1.09–1.47, p = < 0.002) in women, and cancer (OR 1.4, 95% CI 1.09–1.95, p = < 0.012) in men were associated with an increased likelihood of developing LCS.

Conclusion

Lipid metabolism disorders and obesity represent age-independent risk factors for the development of LCS, suggesting that metabolic alterations determine the risk for unfavorable disease courses along all phases of COVID-19.

No increased incidence of venous thrombosis or pulmonary embolism after SARS-CoV-2 vaccination in Germany

Objectives

Vaccination is one of the most effective measures to combat the COVID-19 pandemic. The main reason for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination hesitancy is the potential side-effects. This study aimed to investigate the incidence of venous thrombosis and pulmonary embolism in patients who received SARS-CoV-2 vaccination.

Study design

This was a retrospective cohort study.

Methods

Individuals aged ≥18 years who received an initial vaccination for COVID-19 in one of 1134 general practices in Germany between April and June 2021 were included in the study. Vaccinated patients were matched to unvaccinated individuals by age, sex, index month (April to June 2020 [unvaccinated cohort] or April to June 2021 [vaccinated cohort]) and diagnoses that may be associated with an increased incidence of thrombosis documented within 12 months before the index date. The incidences of thrombosis and non-fatal pulmonary embolism as a function of COVID-19 vaccination were analysed.

Results

The present study included 326,833 individuals who were vaccinated against COVID-19 and 326,833 matched unvaccinated individuals. During the follow-up period, 406 vaccinated patients and 342 individuals in the control group received a diagnosis of thrombosis or non-fatal pulmonary embolism. This resulted in an incidence rate of 11.9 vs 11.3 cases per 1000 patient-years for vaccinated vs unvaccinated individuals, respectively, and a non-significant overall incidence rate ratio (IRR: 1.06; 95% confidence interval [CI]: 0.93–1.22). The highest IRR was observed in the 41–60 years age group (IRR: 1.30; 95% CI: 0.98–1.73), and the lowest IRR was seen in the 18–40 years age group (IRR: 0.6; 95% CI: 0.0–1.05); however, none of the individual age group incidence rates was significant.

Conclusions

The results indicate that the occurrence of thrombosis or pulmonary embolism after COVID-19 vaccination is a coincidental finding rather than a consequence of vaccination.

Hereditary transthyretin-related amyloidosis is frequent in polyneuropathy and cardiomyopathy of no obvious aetiology

BACKGROUND

Hereditary Transthyretin-Related Amyloidosis, a clinically heterogeneous autosomal dominant disease caused by pathogenic variants in the TTR gene, is characterized by the deposition of insoluble misfolded protein fibrils. The diagnosis, especially in non-endemic areas, is typically delayed by 4-5 years; a misdiagnosis due to clinical heterogeneity is common. The study objective was to define the prevalence of Hereditary Transthyretin-Related Amyloidosis in patients with polyneuropathy and/or cardiomyopathy of no obvious aetiology.

METHOD

A multicenter observational "Epidemiological analysis for the hereditary Transthyretin-Related AMyloidosis"-TRAM study was performed in Germany, Austria, and Switzerland.

RESULTS

A total of 5141 participants were recruited by 50 neurologic and 27 cardiologic specialized centres. Genetic analysis demonstrated a 1.1% Hereditary Transthyretin-Related Amyloidosis positivity rate among patients with polyneuropathy and/or cardiomyopathy of not obvious aetiology. Twenty-one various TTR variants (TTR-positive) were identified. Body Mass Index was lower in the TTR-positive patients as an indicator for the involvement of the autonomic nervous system; the age of onset of clinical manifestations was higher in TTR-positive patients. There were no other genotype-phenotype correlations or the prevalence of specific clinical manifestations in TTR-positive patients.

CONCLUSIONS

Our data support the fact that Hereditary Transthyretin-Related Amyloidosis is underdiagnosed in polyneuropathy and cardiomyopathy patients. Routine implementation of genetic testing is recommended in patients with unexplained polyneuropathy and/or cardiomyopathy to accelerate the earlier diagnosis and the time-sensitive treatment initiation.KEY MESSAGESMore than 5.000 participants with CM and/or PNP of no obvious aetiology were recruited in the observational "Epidemiological analysis for the hereditary Transthyretin-Related AMyloidosis" TRAM study and screened for pathogenic TTR variants.The study demonstrated >1% of patients with CM and/or PNP of unclear aetiology are positive for a pathogenic TTR variant.Routine genetic testing is recommended in patients with unexplained CM and/or PNP to accelerate the initial diagnosis and timely treatment initiation.

Impact of the coronavirus 2019 (COVID-19) pandemic on anxiety diagnosis in general practices in Germany

Little is known about the effects of the coronavirus disease-2019 (COVID-19) pandemic on the diagnosis of anxiety disorder. Therefore, the goal of this study was to compare the number of adults with a diagnosis of anxiety disorder and the number of adults newly diagnosed with anxiety disorder in Germany between January-June 2019 and January-June 2020, and to identify potential differences in terms of sociodemographic characteristics, prescriptions and comorbidities between these patients. The study included patients with at least one consultation in one of 1140 general practices in Germany in January-June 2019 and January-June 2020. Sociodemographic characteristics included age and sex, while there were three families of drugs and nine common comorbidities available for the analysis. An increase in the number of patients with anxiety disorder was observed in 2020 compared with 2019 (January: +4%, p = 0.643; February: +4%, p = 0.825; March: +34%, p < 0.001; April: +8%, p = 0.542; May: +2%, p = 0.382; June: +19%, p = 0.043; and March-June: + 19%, p < 0.001). There was also an increase in the number of patients newly diagnosed with anxiety disorder between March-June 2020 and March-June 2019 (11,502 versus 9506; +21%, p-value<0.001). Antidepressants, anxiolytics and herbal sedatives were less frequently prescribed in patients newly diagnosed with anxiety disorder in 2020 than in 2019 (30.4% versus 35.6%, p-value<0.001). Finally, COPD (9.4% versus 7.9%, p-value<0.001) and asthma (11.3% versus 9.7%, p-value<0.001) were more frequent in 2020 than in 2019. Taken these findings together, public health measures are urgently needed to mitigate the negative impact of the COVID-19 pandemic on anxiety disorder.

Fewer non-COVID-19 respiratory tract infections and gastrointestinal infections during the COVID-19 pandemic

For preventing the spread of the coronavirus disease 2019 (COVID‐19) pandemic, measures like wearing masks, social distancing, and hand hygiene played crucial roles. These measures may also have affected the expansion of other infectious diseases like respiratory tract infections (RTI) and gastro‐intestinal infections (GII). Therefore, we aimed to investigate non‐COVID‐19 related RTI and GII during the COVID‐19 pandemic. Patients with a diagnosis of an acute RTI (different locations) or acute GII documented anonymously in 994 general practitioner (GP) or 192 pediatrician practices in Germany were included. We compared the prevalence of acute RTI and GII between April 2019–March 2020 and April 2020–March 2021. In GP practices, 715,440 patients were diagnosed with RTI or GII in the nonpandemic period versus 468,753 in the pandemic period; the same trend was observed by pediatricians (275,033 vs. 165,127). By GPs, the strongest decrease was observed for the diagnosis of influenza (−71%, p < 0.001), followed by acute laryngitis (−64%, p < 0.001), acute lower respiratory infections (bronchitis) (−62%, p < 0.001), and intestinal infections (−40%, p < 0.001). In contrast, the relatively rare viral pneumonia strongly increased by 229% (p < 0.001). In pediatrician practices, there was a strong decrease in infection diagnoses, especially influenza (−90%, p < 0.001), pneumonia (−73%, p < 0.001 viral; −76%, p < 0.001 other pneumonias), and acute sinusitis (−66%, p < 0.001). No increase was observed for viral pneumonia in children. The considerable limitations concerning social life implemented during the COVID‐19 pandemic to combat the spread of SARS‐CoV‐2 also resulted in an inadvertent but welcome reduction in other non‐Covid‐19 respiratory tract and gastro‐intestinal infections.

By general practices, in the pandemic time period, the strong decrease was observed for the diagnosis of influenza, acute laryngitis bronchitis, and intestinal infections.

In contrast, the relatively rare viral pneumonia strongly increased in general practices.

In pediatrician practices, there was a strong decrease in influenza, pneumonia, and acute sinusitis.

No increase was observed for viral pneumonia in children.

Value of Left Ventricular Feature Tracking Strain Analysis for Detection of Early Cardiac Involvement in Fabry Disease (FD)

Purpose: Detection of cardiac involvement in Fabry disease (FD) is of high importance for treatment management. Native T1 mapping especially showed great potential for detection of early cardiac manifestations. Echocardiographic studies showed strain abnormalities in FD patients, but data on MRI feature tracking strain analysis (FT-SA) is limited. Therefore, the aim of our study was to evaluate the potential of FT-SA compared to native T1 and the FD specific biomarker Globotriaosylsphingosine (LysoGb3). Methods: 28 consecutive FD patients (18 female; 47.8 years ± 17.4 standard deviation (SD)) and 28 control subjects (18 female; 46.6 years ± 18.2 SD) underwent cardiac MRI at 1.5 Tesla. Global native T1 times and left ventricular FT-SA were evaluated. Results were correlated to serum Lyso-Gb3-levels. Results: Native T1 times, global longitudinal (GLS) and global radial strain (GRS) were significantly reduced in FD patients (p < 0.0064, p = 0.0009 and p = 0.0184, respectively). Moreover, native T1 times and GLS were significantly lower in Lyso-Gb3 positive FD patients (p < 0.005 and p = 0.03). GLS, native T1 times showed significant moderate correlations to LysoGb3 (p = 0.002 and p < 0.001). Furthermore, GLS and native T1 times reduce when LysoGb3 was elevated and increasingly with presence of left ventricular hypertrophy (LVH) or late gadolinium enhancement (LGE). Conclusions: Native T1 times and strain values differ significantly between FD patients and control subjects and showed promising correlations to the FD specific biomarker LysoGb3. We therefore conclude that strain abnormalities occur early beside native T1 reductions in cardiac FD involvement. Large scale trials are needed to verify our findings.

Predicting the Risk of Ischemic Stroke in Patients Treated with Novel Oral Anticoagulants: A Machine Learning Approach

INTRODUCTION

The aim of this cohort study was to estimate the predictors of ischemic stroke in patients treated with non-vitamin K antagonist oral anticoagulants (NOACs) in a large database containing data from general practitioners in Germany using machine learning methods.

METHODS

This retrospective cohort study included 39,652 patients with a diagnosis of atrial fibrillation (AF) and an initial prescription of NOAC in 1,278 general practices in Germany between January 2011 and December 2018. Of 39,652 patients, 2,310 (5.8%) receive the first stroke or TIA diagnosis during the follow-up time (average follow-up time 2.5 [SD: 1.8] years). Sub-Population Optimization and Modeling Solutions (SOMS) tool was used to identify subgroups at a higher risk of stroke compared to the overall population receiving NOAC based on 37 different variables.

RESULTS

Using SOMS, a total of 9 variables were considered important for the stroke prediction. Age had 59.1% of prediction importance, following by ischemic heart diseases (10.6%), urinary tract infections (4.6%), dementia (3.5%), and male sex (3.5%). Further variables with less importance were dizziness (2.2%), dorsalgia (1.5%), shoulder lesions (1.1%), and diabetes mellitus (1.1%).

DISCUSSION/CONCLUSIONS

The stroke risk in AF patients treated with NOAC could be predicted based on comorbidities like ischemic heart diseases, urinary tract infections, and dementia additionally to age and male sex. Knowing and addressing these factors may help reduce the risk of stroke in this patient population.

Prevalence of, and factors associated with, long-term COVID-19 sick leave in working-age patients followed in general practices in Germany

Objectives

To investigate the prevalence of, and the factors associated with, long-term sick leave in working-age patients diagnosed with COVID-19 in general practices in Germany.

Methods

Patients aged 18–65 years diagnosed with COVID-19 in any of 1255 general practices in Germany between March 2020 and February 2021 were included in the study. Long-term sick leave was defined as sick leave of at least 4 weeks. The association between predefined independent variables and long-term sick leave was studied using an adjusted logistic regression model.

Results

This study included 30 950 patients diagnosed with COVID-19 (51.7% women, mean (standard deviation) age 41.5 (±13.0) years). The prevalence of long-term sick leave was 5.8%. Female sex, older age, and several conditions (noninfective enteritis and colitis; reaction to severe stress, and adjustment disorders; atopic dermatitis; mononeuropathies; reflux diseases; diabetes mellitus; and hypertension) were positively and significantly associated with long-term sick leave.

Conclusion

Long-term sick leave was relatively rare in COVID-19 patients followed in general practices in Germany. These results should be confirmed or invalidated in other settings and countries.

(Absence of) Association Between Non-Vitamin K Antagonist Oral Anticoagulant Therapy and Urinary Tract Infection in Patients With Atrial Fibrillation

ABSTRACT

The aim of the present study is to identify a potential association of urinary tract infections (UTI) in a large population of patients receiving oral anticoagulation therapy treated in general practices in Germany. This study contains patients diagnosed with atrial fibrillation who received at least one prescription of either non-vitamin K antagonist oral anticoagulation (NOAC) or vitamin K antagonists (VKA) within January 2015 and December 2018. The incidence of UTI was examined cumulatively on the basis of Kaplan-Meier methods and was complemented by incidence rates measured in cases per 1000 patient years. Sex-stratified Cox regressions were conducted to examine possible associations in specific sex groups. The study comprised 26,934 patients receiving NOAC therapy and 8121 patients treated with VKA agents. Within a period of 5 years, slightly more NOAC than VKA users were diagnosed with UTI (20.3% vs. 19.3%), whereas the incidence rate was slightly higher in patients receiving NOAC therapy than in those under VKA treatment (50.8 cases vs. 50.5 cases in 1000 patient years). There was no significant association between direct oral anticoagulants versus vitamin K antagonists and infections of the urinary tract. Our study did not identify any significant association between therapy with direct oral anticoagulants versus vitamin K anticoagulants and UTI in patients diagnosed with atrial fibrillation in general practices in Germany. Because current findings regarding the risk of UTI in patients receiving oral anticoagulation therapy remain limited and contradictory, further investigations including a broad patient population are necessary to determine patients at risk for UTI and reconcile conflicting evidence.

Is there an association between multiple sclerosis and osteoarthritis in Germany? A retrospective cohort study of 8,600 patients from Germany

OBJECTIVES

The goal of this retrospective cohort study was to investigate the multiple sclerosis-osteoarthritis relationship in adults followed in general practices in Germany.

METHODS

Patients aged 18-70 years who were diagnosed for the first time with multiple sclerosis in one of 1,193 general practices in Germany between 2005 and 2018 (index date) were included in this retrospective cohort study. Patients without multiple sclerosis were matched (1:1) to those with multiple sclerosis by sex, age, index year, general practice, obesity, injuries, and other types of arthritis (index date: a randomly selected visit date). The association between multiple sclerosis and the 10-year incidence of osteoarthritis was analyzed using Cox regression models.

RESULTS

There were 4,300 patients with multiple sclerosis and 4,300 patients without multiple sclerosis included in this study. The proportion of women was 69.3% and mean (SD) age was 43.6 (12.6) years. There was no significant association between multiple sclerosis and incident osteoarthritis in the overall sample (HR = 0.95, 95% CI: 0.83-1.09) as well as sex and age subgroups.

CONCLUSIONS

Based on these findings, multiple sclerosis is not significantly associated with osteoarthritis. Further studies of longitudinal nature are warranted to corroborate or invalidate these results.

Increased Incidence of Stroke and Transient Ischemic Attack in Patients with Rheumatoid Arthritis and Ankylosing Spondylitis in Germany

BACKGROUND

As chronic inflammatory diseases may be associated with an increased risk of vascular events, the aim of the present study was to assess the incidence of stroke and transient ischemic attack (TIA) in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS).

METHODS

Patients diagnosed with RA and AS in 1,262 general practices in Germany between 2000 and 2015 were selected. RA and AS patients were matched to patients without RA or AS using propensity scores based on age, sex, physician, co-diagnoses, and co-therapies. The Kaplan-Meier curves and Cox regression models were used to study the incidence of stroke and TIA as a function of RA and AS.

RESULTS

In the study population (N = 29,106; mean age 54.8 years; 65% women), 24,580 patients had RA and 4,526 had AS. RA was significantly associated with the stroke (hazard ratio [HR] = 1.42, confidence interval [CI]: 1.25-1.60) and TIA (HR = 1.69, CI: 1.46-1.95). The association between RA and stroke was strongest in the age group 18-40 years (HR = 3.45, CI: 1.30-9.18). The HR for stroke in AS was 1.41 (CI: 0.99-2.00) and for TIA 1.62 (1.08-2.44).

CONCLUSION

RA was significantly associated with stroke and TIA, with young patients being at a particularly increased risk. AS was tendentially associated with stroke and TIA.

Multiple Sclerosis and Incidence of Urinary and Fecal Incontinence in Almost 9,000 Patients Followed Up for up to 10 Years in Germany

BACKGROUND

There is a lack of large studies on urinary (UI) and fecal incontinence (FI) following multiple sclerosis (MS) diagnosis. Thus, our goal was to investigate the association between MS and the incidence of UI and FI in patients followed up for up to 10 years in Germany.

METHODS

This study included patients who received an initial documentation of MS diagnosis in general practices in Germany during 2005-2018 (index date). Patients without MS were matched (1:1) to those with MS using propensity scores based on sex, age, index year, follow-up time (in years), general practice, and the Charlson Comorbidity Index score (index date: a randomly selected visit date).

RESULTS

This retrospective study included 4,461 patients with MS and 4,461 patients without MS (69.9% women; mean [SD] age 44.2 [12.7] years). Within 10 years of index date, a higher proportion of patients with MS were diagnosed with UI (11.7 vs. 3.2%) and FI (2.3 vs. 0.5%; p values <0.001) than those without MS. MS was further found to be associated with both UI (hazard ratio [HR] = 3.85) and FI (HR = 5.38; p values <0.001) in the Cox regressions.

CONCLUSIONS

UI and FI are frequent complications of MS, and the presence of these complications should be regularly assessed in primary care practices.

Consultations Decline for Stroke, Transient Ischemic Attack, and Myocardial Infarction during the COVID-19 Pandemic in Germany

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic raises the concern that other non-COVID conditions will be affected by a decline in care. Therefore, we aimed to investigate the decline in ambulatory presentations for vascular events (stroke, transient ischemic attack [TIA], and myocardial infarction [MI]) during the COVID-19 pandemic.

METHODS

Patients with a diagnosis of ischemic stroke, TIA, or MI documented anonymously in 1,262 general practices in Germany were included. We studied the differences between 2019 and 2020 (between April and June) in terms of rates and baseline characteristics by comparing monthly absolute frequencies.

RESULTS

A total of 3,496 patients with stroke (mean age: 72.2 years), 1,608 patients with TIA (mean age: 71.5 years), and 2,385 patients with MI (mean age: 66.8 years) were identified between April and June 2020, indicating a decrease of 10% (stroke), 16% (TIA), and 9% (MI) compared to 2019. For patients with stroke, the decrease in men was 13% (women: -6%) but reached 17% in the age category 51-60 years. For MI, the decrease was only obvious in males (14%). The largest decrease in stroke (-17%) and MI (-19%) was noted in April, while that for TIA occurred in May (-22%). In June for all 3 conditions, the previous year's level was achieved. Only in TIA, the age differs between 2019 and 2020 (mean age: 69.9 vs. 71.5 years; p < 0.05). In patients with stroke and MI, the proportions of men were lower in 2019 than in 2020 (stroke: 54.8-50.5%, p < 0.05 and MI: 64-60.2%, p < 0.05).

CONCLUSION

Although the decline in the number of patients presenting with stroke, TIA, and MI was not as noticeable in the ambulatory sector as it was in the area of emergency hospital-based care, our data indicate that the COVID-19 pandemic affected all sectors within the medical care system.

Flexible endoscopic evaluation of swallowing (FEES) to determine neurological intensive care patients' oral diet

PURPOSE

Dysphagia is common in critically ill neurological patients and is associated with a high mortality and morbidity. Data on the usefulness of flexible endoscopic examination of swallowing (FEES) in neurological intensive care unit (ICU) patients are lacking, raising the need for evaluation.

METHOD

FEES was performed in neurological intensive care patients suspected of dysphagia. We correlated findings with baseline data, disability status, pneumonia and duration of hospitalisation, as well as a need for mechanical ventilation or tracheotomy.

RESULT

This analysis consisted of 125 patients with suspected dysphagia. Most of the patients (81; 64,8%) suffered from acute stroke. Dysphagia was diagnosed using FEES in 90 patients (72%). FEES results led to dietary modifications in 80 patients (64%). The outcome at discharge was worse in dysphagic stroke patients diagnosed by FEES as compared to non-dysphagic stroke patients (p = 0.009). Patients without oral diet had higher need for intubation (p = 0.007), tracheotomy (p = 0.032) and higher mortality (p < 0.001) in comparison to patients with at least small amounts of oral intake.

CONCLUSION

As the clinical assessment of the patients often classified the dysphagia incorrectly, the broad use of FEES in ICU patients might help to adequately adjust patients' oral diet. This knowledge might contribute to lower mortality and morbidity.

Proton pump inhibitor use is associated with a variety of infections in patients with liver cirrhosis

There is evidence that intake of proton pump inhibitors (PPI) increases the risk for spontaneous bacterial peritonitis (SBP) in patients with liver cirrhosis. However, data regarding the impact of PPI intake on occurrence of infections other than SBP are still lacking.We hypothesized that PPI use is associated with a higher rate of infections other than SBP in patients with liver cirrhosis.The current case-control study sample included patients with liver cirrhosis from the Disease Analyzer database (IQVIA), which compiles data such as risk factors, drug prescriptions and diagnoses obtained from general practitioners and specialists in Germany. In total, 2,823 patients with infections were matched with 2,823 patients without infections by propensity scores. For quantification of PPI use the prescribed quantity of PPI during the past 12 months before index date was analyzed.Frequency of PPI users was significantly higher in patients with infections than in patients without infections (47.9% vs 37.9%). In regression analysis, PPI use was significantly associated with the occurrence of infections overall (OR 1.55, 95% CI 1.39-1.72, P < .001), and associated with the occurrence of lower respiratory tract infections, urinary tract infections and infectious gastroenteritis. There was no association between PPI use and skin infections. Pantoprazole and omeprazole were the most frequently prescribed PPIs and were both independently associated with the occurrence of infections.PPI use may be associated with infections other than SBP in patients with liver cirrhosis. Prescription of PPI should be limited to patients with a clear indication.

Factors associated with fracture after stroke and TIA: a long-term follow-up

We assessed the long-term incidence of fractures after stroke and TIA and analyzed associated factors. The fracture incidence increases with age and is higher in stroke than in TIA. Dementia is associated with fractures after both. Our results indicate tailored measures are necessary for preventing fractures after stroke or TIA.

INTRODUCTION

In the present study, we aimed to assess the long-term incidence of fractures and analyze associated factors after stroke or transient ischemic attack (TIA).

METHODS

The current cohort study included patients who had received an initial ischemic stroke or TIA diagnosis documented anonymously in the Disease Analyzer database (IQVIA) between 2000 and 2016 by physicians in 1262 general practices in Germany. Univariate Cox and multivariate regression models were carried out.

RESULTS

Three groups (stroke, TIA, no stroke/TIA), each with 12,265 individuals, were selected (mean age 67.3 years, 48.1% female). A fracture was diagnosed in 12.9% of stroke patients and in 11.4% of TIA patients. Among male stroke patients, 11.1% had a fracture (15.4% among female stroke patients). The hazard ratio (HR) for fractures after stroke was 1.26 (CI: 1.15-1.39) and for fractures after TIA, it was 1.14 (CI: 1.03-1.25). In female stroke patients, the HR for fractures was 1.32 (CI: 1.15-1.60), while in males, it was 1.20 (CI: 1.03-1.39). Among TIA patients, females had an elevated HR for fractures (HR: 1.21; CI: 1.06-1.37). In individuals aged ≥ 80 years, an increased risk for fractures was only detected among TIA patients (HR: 1.26; CI: 1.05-1.51). Dementia and non-opioid analgesic therapy were positively associated with fracture after both stroke and TIA.

CONCLUSION

Stroke was positively associated with fracture in patients < 80 years, while TIA was positively associated with fracture in patients ≥ 80 years and females. Dementia and analgesic therapy were also associated with fracture after either stroke or TIA.

Osteoarthritis and incidence of stroke and transient ischemic attack in 320,136 adults followed in general practices in the United Kingdom

OBJECTIVE

The goal of this study was to investigate the relationship of osteoarthritis with stroke and transient ischemic attack in the United Kingdom.

METHODS

This study included patients who received a first diagnosis of osteoarthritis in one of 256 general practices in the United Kingdom between 1997 and 2016 (index date). Patients without osteoarthritis were matched (1:1) to those with osteoarthritis using propensity scores based on sex, age, index year, general practice, and vascular risk factors documented in the 12 months prior to the index date (hypertension, obesity, diabetes mellitus, dyslipidemia, and atrial fibrillation). For individuals without osteoarthritis, the index date corresponded to a randomly selected visit date between 1997 and 2016. The relationship between osteoarthritis and the incidence of both stroke and transient ischemic attack was studied using Kaplan-Meier curves and Cox regression analyses.

RESULTS

This study included 160,068 patients with osteoarthritis and 160,068 patients without osteoarthritis (61.6% women; mean age [standard deviation] 64.2 [14.2] years). The 10-year incidence of stroke (4.5% versus 3.0%) and transient ischemic attack (3.3% versus 2.0%) was significantly higher in individuals with than in those without osteoarthritis. The Cox regression analyses also showed that osteoarthritis was positively associated with both stroke (hazard ratio [HR]=1.45, 95% confidence interval [CI]=1.39-1.51) and transient ischemic attack (HR=1.55, 95% CI=1.47-1.63).

CONCLUSIONS

These findings suggest that osteoarthritis may be associated with an increase in the incidence of stroke and transient ischemic attack. Further research of longitudinal design is warranted to confirm or reject these results.

Impaired Cerebrovascular Autoregulation in Large Vessel Occlusive Stroke after Successful Mechanical Thrombectomy: A Prospective Cohort Study

INTRODUCTION

Successful thrombectomy improves morbidity and mortality after stroke. The present prospective, observational cohort study investigated a potential correlation between the successful restoration of tissue perfusion by mechanical thrombectomy and intact cerebrovascular autoregulation (CA).

OBJECTIVE

Status of CA in patients with large vessel occlusive stroke after thrombectomy.

METHODS

After thrombectomy CA was measured using transcranial Doppler ultrasound. For this purpose a moving correlation index (Mxa) based on spontaneous arterial blood pressure fluctuations and corresponding cerebral blood flow velocity changes was calculated. CA impairment was defined by Mxa values more than .3.

RESULTS

Twenty patients with an acute occlusion of the middle cerebral artery or distal internal carotid artery were included. A successful recanalization of the occluded vessel via interventional thrombectomy was achieved in 10 of these patients (successful recanalization group), while in 10 patients mechanical recanalization failed or could not be applied (no recanalization group). Mean Mxa at stroke side was .58 ± .21 Table 2a in patients with successful intervention. At the unaffected hemisphere Mxa was .50 ± .20 Table 2a in successful recanalization group and .45 ± .24 Table 2b in no recanalization group without statistically significant differences. Based on the previously defined Mxa cut off more than .3, CA impairment was observable in all successful recanalized patients and in 8 of 10 patients with unsuccessful interventional treatment.

CONCLUSIONS

These results suggest that brain perfusion may be affected due to impaired CA even after successful mechanical thrombectomy. Therefore, a tight blood pressure management is of great importance in post-thrombectomy stroke treatment to avoid cerebral hypo- and hyperperfusion.

Long-term risk of stroke and its predictors in transient ischaemic attack patients in Germany

BACKGROUND AND PURPOSE

Little is known about the long-term association between transient ischaemic attack (TIA) and stroke. Therefore, the goal of this study was to analyze the long-term risk of stroke and associated predictors in a large cohort of TIA patients followed in general practices in Germany.

METHODS

This study included patients with an initial TIA diagnosis and subsequently followed up in one of 1262 general practices in Germany between January 2007 and December 2016 (N = 19 824 patients). The primary outcome of the study was the risk of ischaemic stroke within 10 years of the initial diagnosis of TIA. The secondary outcome was the identification of demographic, clinical and pharmaceutical variables significantly associated with stroke in TIA patients.

RESULTS

Within 10 years of the initial TIA diagnosis, 18.3% of individuals were diagnosed with stroke. Age was positively associated with stroke, with hazard ratios ranging from 1.88 in patients aged 51-60 years to 4.00 in those aged >80 years (reference group: patients aged ≤50 years). Furthermore, male sex, hypertension, diabetes mellitus, atrial fibrillation and ischaemic heart diseases had an additional impact on the risk of stroke. Finally, new oral anticoagulants, heparins, diuretics, angiotensin II receptor blockers and platelet aggregation inhibitors were identified as protective factors.

CONCLUSIONS

In a cohort of almost 20 000 TIA patients, 18.3% were diagnosed with stroke within 10 years after the TIA index event. Several demographic, clinical and pharmaceutical variables significantly predicted the long-term risk of stroke in TIA patients.

Adjustment of oral diet based on flexible endoscopic evaluation of swallowing (FEES) in acute stroke patients: a cross-sectional hospital-based registry study

BACKGROUND

Diagnosing dysphagia in acute stroke patients is crucial, as this comorbidity determines morbidity and mortality; we therefore investigated the impact of flexible nasolaryngeal endoscopy (FEES) in acute stroke patients.

METHODS

The FEES investigation as performed in acute stroke patients treated at a large university hospital, allocated as a standard procedure for all patients suspected of dysphagia. We correlated our findings with baseline data, disability status, pneumonia, duration of hospitalisation, necessity for mechanical ventilation and treatment on the intensive care unit. The study was designed as a cross-sectional hospital-based registry.

RESULTS

We investigated 152 patients. The median age was 73; 94 were male. Ischemic stroke was diagnosed in 125 patients (82.2%); 27 (17.8%) suffered intracerebral haemorrhage. Oropharyngeal dysphagia was diagnosed in 72.4% of the patients, and was associated with higher stroke severity on admission (median NIHSS 11 [IQR 6-17] vs. 7 [4-12], p = .013; median mRS 5 [IQR 4-5] vs. 4 [IQR 3-5], p = .012). Short-term mortality was higher among patients diagnosed with dysphagia (7.2% vs. 0%, p = .107). FEES examinations revealed that only 30.9% of the patients had an oral diet appropriate for their swallowing abilities. A change of oral diet was associated with a better outcome at discharge (mRS; p = .006), less need of mechanical ventilation (p = .028), shorter period of hospitalisation (p = .044), and lower rates of pneumonia (p = .007) and mortality (p = .011).

CONCLUSION

Due to the inability of clinical assessments to detect silent aspiration, FEES might be better suited to identify stroke patients at risk and may contribute to a better functional outcome and lower rates of pneumonia and mortality. Our findings also point to a low awareness of dysphagia, even in a specialised stroke centre. FEES in acute stroke patients helps to adjust the oral diet for the vast majority of stroke patients (69.1%) based on their swallowing abilities, potentially avoiding severe complications.

Role of PI3K/Akt and MEK/ERK Signalling in cAMP/Epac-Mediated Endothelial Barrier Stabilisation

Background and Aims

Activation of the cAMP/Epac signalling stabilises endothelial barrier function. Moreover, its activation is accompanied by an activation of PI3K/Akt and MEK/ERK signalling in diverse cell types but their impact on endothelial barrier function is largely unknown. Here the role of PI3K/Akt and MEK/ERK signalling in cAMP/Epac-mediated endothelial barrier stabilisation was analysed.

Methods

Endothelial barrier function was analysed in cultured human umbilical vein endothelial cells (HUVECs) by measuring flux of albumin. A modified cAMP analogue 8-pCPT-2′-O-Me-cAMP (Epac agonist) was used to specifically activate cAMP/Epac signalling.

Results

Epac agonist reduces the basal and attenuates thrombin-induced endothelial hyperpermeability accompanied by an activation of PI3K/Akt and MEK/ERK signalling. The qPCR data demonstrate HUVECs express PI3Kα, PI3Kβ, and PI3Kγ but not PI3Kδ isoforms. The western blot data demonstrate Epac agonist activates PI3Kα and PI3Kβ isoforms. Inhibition of MEK/ERK but not PI3K/Akt pathway potentiates the endothelial barrier protective effects of cAMP/Epac signalling. Inhibition of MEK/ERK signalling in the presence of Epac agonist induces a reorganisation of actin cytoskeleton to the cell periphery, enhanced VE-cadherin localisation at cell-cell junctions, and dephosphorylation of myosin light chains (MLC) but not inhibition of RhoA/Rock signalling. Moreover, Epac agonist promotes endothelial cell (EC) survival via reduction in activities of pro-apoptotic caspases in a PI3K/Akt and MEK/ERK signalling-dependent manner.

Conclusion

Our data demonstrate that the Epac agonist simultaneously activates diverse signalling pathways in ECs, which may have differential effects on endothelial barrier function. It activates PI3K/Akt and MEK/ERK signalling which mainly govern its pro-survival effects on ECs. Inhibition of MEK/ERK but not PI3K/Akt signalling enhances barrier stabilising and barrier protective effects of cAMP/Epac activation.

Chemical Compounds Used In This Study

8-pCPT-2′-O-Me-cAMP (PubChem CID: 9913268); Akt inhibitor VIII (PubChem CID: 10196499); AS-252424 (PubChem CID: 11630874); IC-87114 (PubChem CID: 9908783); PD 98059 (PubChem CID: 4713); PIK-75 (PubChem CID: 10275789); TGX-221 (PubChem CID: 9907093); Thrombin (PubChem CID: 90470996); U0126 (PubChem CID: 3006531); Wortmannin (PubChem CID: 312145).

Venous access closure using a purse-string suture without heparin antagonism or additional compression after MitraClip implantation

OBJECTIVES

This observational study was designed to analyze the safety and feasibility of percutaneous skin closure using a purse-string suture (PSS) after MitraClip procedures.

METHODS

Forty-one consecutive patients with severe mitral regurgitation who underwent MitraClip implantation from February 2018 to January 2019 at our institution received a PSS after percutaneous mitral valve repair before withdrawal of the 24-French (Fr) sheath. Protamine was not administered after venous closure at procedure end. No compression therapy (e.g., compression bandage or pneumatic compression device) was used. Patients were on bed rest for 6 hrs prior to suture removal, which was accomplished 18-24 hrs after MitraClip implantation. We analyzed the occurrence of any vascular or thromboembolic complications during the hospital stay and until the 3-month follow-up.

RESULTS

The primary endpoint-any access-related major complication-did not occur in any patients. None of the patients revealed a pseudoaneurysm or an arteriovenous fistula, a thromboembolic complication, or local stenosis related to the PSS closure. The secondary endpoint- minor access-site vascular complications (hematoma)- was documented in six (14.6%) patients.

CONCLUSIONS

Venous access-site closure with a PSS without the need for protamine administration or compression therapy appears to be safe and feasible in patients undergoing MitraClip implantation with access via a 24-Fr sheath.

Late Detection of Atrial Fibrillation after Stroke: Implications for the Secondary Prevention

BACKGROUND

This study is aimed at investigating the incidence of atrial fibrillation (AF) within 5 years after an acute cerebrovascular event in AF-naive patients and its relevance for secondary prevention.

METHODS

The current case-control study sample included patients who had received an initial ischemic stroke diagnosis documented in the Disease Analyzer database (IQVIA), which compiles data such as risk factors, drug prescriptions, and diagnoses obtained from 1,262 general practices in Germany.

RESULTS

After the selection procedure, the stroke and non-stroke groups each included 22,774 patients. In both groups, the mean age of the population was 68.0 years (SD ±12 years), and the proportion of male participants was 51.1%. Within 5 years of follow-up, we calculated a higher probability for detecting AF in stroke patients than in controls (hazard ratio 4.95; 95% CI 1.93-2.09, p < 0.001). In the stroke group, AF was detected in 2,369 individuals (10.4%), whereas AF was only evident in 1,101 patients (4.8%) in the non-stroke group. In 1,741 (73.5%) patients (out of 2,369), oral anticoagulants had been prescribed after the AF diagnosis. In stroke patients, factors like diabetes mellitus and ischemic heart disease were associated with restraint in prescribing oral anticoagulants; age did not influence the decision for or against oral anticoagulants (mean age 72.9 vs. 72.7 years).

CONCLUSION

A recent stroke is a strong preconditioning factor for detecting AF within 5 years after an acute event. The majority of these patients are treated with oral anticoagulants, regardless of their age.

Increased risk for cancer after stroke at a young age: etiological relevance or incidental finding?

BACKGROUND

Etiological factors, such as a malignant disease, in young stroke patients are often neglected. Therefore, in this study, we aimed to investigate the risk of developing cancer in young stroke survivors.

METHODS

The current case-control study sample included patients who received an initial ischemic stroke diagnosis documented in the Disease Analyzer database (IQVIA), which compiles data such as risk factors, drug prescriptions, and diagnoses obtained from general practitioners and specialists.

RESULTS

The stroke and non-stroke groups included 18,668 patients each; each group had 2836 (15.3%) participants ≤ 55 years. The cancer incidence in the stroke group over the age of 55 years was higher than in the younger subgroup (29.4% versus 17.3%). The proportions of cancer patients within 10 years of follow-up were higher in the stroke group versus the non-stroke group, as well as in the subgroup of patients aged ≤ 55 versus patients > 55 years (17.3% versus 9.5% and 29.4% versus 24.9%, respectively). The calculated hazard ratio for developing cancer within 10 years of follow-up was higher in the younger stroke population (≤ 55 years) than in the older population (hazard ratio: 1.47 (CI 1.18-1.83) versus 1.17 (CI 1.10-1.25).

CONCLUSION

In our cohort, young individuals aged ≤ 55 years who suffered a stroke had twice as high risk for developing cancer within 10 years after the index event compared to the control group. Stroke might have implication regarding the subsequent development of cancer and vice versa.

Sphenopalatine Ganglion Stimulation to Augment Cerebral Blood Flow

Background and Purpose—

Many patients with acute ischemic stroke are not eligible for thrombolysis or mechanical reperfusion therapies due to contraindications, inaccessible vascular occlusions, late presentation, or large infarct core. Sphenopalatine ganglion (SPG) stimulation to enhance collateral flow and stabilize the blood-brain barrier offers an alternative, potentially more widely deliverable, therapy.

Methods—

In a randomized, sham-controlled, double-masked trial at 41 centers in 7 countries, patients with anterior circulation ischemic stroke not treated with reperfusion therapies within 24 hours of onset were randomly allocated to active SPG stimulation or sham control. The primary efficacy outcome was improvement beyond expectations on the modified Rankin Scale of global disability at 90 days (sliding dichotomy), assessed in the modified intention-to-treat population. The initial planned sample size was 660 patients, but the trial was stopped early when technical improvements in device placement occurred, so that analysis of accumulated experience could be conducted to inform a successor trial.

Results—

Among 303 enrolled patients, 253 received at least one active SPG or sham stimulation, constituting the modified intention-to-treat population (153 SPG stimulation and 100 sham control). Age was median 73 years (interquartile range, 64–79), 52.6% were female, deficit severity on the National Institutes of Health Stroke Scale was median 11 (interquartile range, 9–15), and time from last known well median 18.6 hours (interquartile range, 14.5–22.5). For the primary outcome, improved 3-month disability beyond expectations, rates in the SPG versus sham treatment groups were 49.7% versus 40.0%; odds ratio, 1.48 (95% CI, 0.89–2.47); P =0.13. A significant treatment interaction with stroke location (cortical versus noncortical) was noted, P =0.04. In the 87 patients with confirmed cortical involvement, rates of improvement beyond expectations were 50.0% versus 27.0%; odds ratio, 2.70 (95% CI, 1.08–6.73); P =0.03. Similar response patterns were observed for all prespecified secondary efficacy outcomes. No differences in mortality or serious adverse event safety end points were observed.

Conclusions—

SPG stimulation within 24 hours of onset is safe in acute ischemic stroke. SPG stimulation was not shown to statistically significantly improve 3-month disability above expectations, though favorable outcomes were nominally higher with SPG stimulation. Beneficial effects may distinctively be conferred in patients with confirmed cortical involvement. The results of this study need to be confirmed in a larger pivotal study.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov . Unique identifier: NCT03767192.

Publisher Correction: Multiancestry genome-wide association study of 520,000 subjects identifies 32 loci associated with stroke and stroke subtypes

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Positive Effect of Steroids in Posterior Reversible Encephalopathy Syndrome

We present a case of posterior reversible encephalopathy syndrome with severe clinical manifestation. Apart from initial aphasia, hemiparesis, and a generalized seizure, the patient had a prolonged loss of consciousness. Although blood pressure was normalized, the clinical status deteriorated continuously. After adding steroids to the therapy, the patient recovered rapidly, suggesting that this could have been a useful therapeutic approach. Even the vasogenic edema in the cerebral magnetic resonance imaging disappeared shortly within 6 days.

Assessment of Cardiac Involvement in Fabry Disease (FD) with Native T1 Mapping

Purpose Fabry disease (FD) is an X-linked multi-organ disorder of lysosomal metabolism with cardiac disease being the leading cause of death. Identifying early FD-specific pathologies is important in the context of maximum therapeutic benefit in these stages. Therefore, the aim of this study was to investigate the value of quantitative cardiac T1 mapping as a potential disease-specific surrogate.

Methods 16 consecutive FD patients (9 female, 7 male; median age: 54 years, IQR 17) and 16 control patients (9 female, 7 male; median age: 52 years, IQR 20) were investigated at 1.5 Tesla. Native T1 mapping was performed using a modified look locker inversion recovery sequence (MOLLI) and native T1 times were measured within the septal myocardium at the midventricular short-axis section. Also functional parameters, left ventricular morphology, presence of late-gadolinium enhancement, cTnI- and Lyso-Gb3-Levels were evaluated.

Results The median native septal T1 time for FD was 889.0 ms and 950.6 ms for controls (p < 0.003). LGE and positive cTnI values (0.26 ± 0.21) were present in 5 FD patients (31.25 %), and left ventricular hypertrophy (LVH) was present in 4 FD patients (25.00 %). The 4 cTnI and 8 Lyso-Gb3 positive FD patients had significantly lower native T1 values (p < 0.05, respectively p < 0.01). Assuming a T1 cut-off value of 900 ms for the identification of increased cardiac lipid deposit, 9 patients with FD (56.25 %) had pathologic values (4 patients cTnI and 8 patients Lyso-Gb3 positive). Moreover, native septal T1 showed a good negative correlation to Lyso-Gb3 (r = – 0.582; p = 0.018).

Conclusion A pathologic cardiac native T1 time obviously reflects cardiac involvement in the scope of FD at tissue level. In the future native T1 mapping as an imaging biomarker might allow identification of early stages of cardiac involvement in FD before morphological changes are obvious.

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