German primary care data collection projects: a scoping review

BACKGROUND

The widespread use of electronic health records (EHRs) has led to a growing number of large routine primary care data collection projects globally, making these records a valuable resource for health services and epidemiological and clinical research. This scoping review aims to comprehensively assess and compare strengths and limitations of all German primary care data collection projects and relevant research publications that extract data directly from practice management systems (PMS).

METHODS

A literature search was conducted in the electronic databases in May 2021 and in June 2022. The search string included terms related to general practice, routine data, and Germany. The retrieved studies were classified as applied studies and methodological studies, and categorised by type of research, subject area, sample of publications, disease category, or main medication analysed.

RESULTS

A total of 962 references were identified, with 241 studies included from six German projects in which databases are populated by EHRs from PMS. The projects exhibited significant heterogeneity in terms of size, data collection methods, and variables collected. The majority of the applied studies (n = 205, 85%) originated from one database with a primary focus on pharmacoepidemiological topics (n = 127, 52%) including prescription patterns (n = 68, 28%) and studies about treatment outcomes, compliance, and treatment effectiveness (n = 34, 14%). Epidemiological studies (n = 77, 32%) mainly focused on incidence and prevalence studies (n = 41, 17%) and risk and comorbidity analysis studies (n = 31, 12%). Only 10% (n = 23) of studies were in the field of health services research, such as hospitalisation.

CONCLUSION

The development and durability of primary care data collection projects in Germany is hindered by insufficient public funding, technical issues of data extraction, and strict data protection regulations. There is a need for further research and collaboration to improve the usability of EHRs for health services and research.

[BeoNet-Halle-development of a multifunctional database for the automated extraction of healthcare data from general practitioner and specialist practices]

The Beobachtungspraxennetzwerk Halle (BeoNet-Halle) is an innovative database of outpatient care that has been collecting patient data from participating primary care and specialty practices throughout Germany since 2020 and making it available for research and care. The database is set up and maintained by the Institute of Medical Epidemiology, Biometrics and Informatics and the Institute of General Practice and Family Medicine of the Martin Luther University Halle-Wittenberg. Furthermore, the Data Integration Center of the University Medical Center Halle is involved in the project. In principle, anonymized and pseudonymized patient data from all commercially available practice management systems should flow into the databases.In this article, we describe the structure and methods of the multi-purpose database BeoNet and quantify the current data stock. The workflow of collection, transfer, and storage of broad consents is described and advantages and limitations of the database are discussed.BeoNet-Halle currently contains anonymized data of approximately 73,043 patients from five physician practices. Furthermore, it includes data from more than 2,653,437 ICD-10 diagnoses, 1,403,726 prescriptions, and 1,894,074 laboratory results. Pseudonymized data were successfully exported from 481 patients.BeoNet-Halle enables an almost seamless representation of the care provided in the participating practices. In the future, the database will map patient treatment pathways across practices and provide high-quality care data to contribute to health policy decision-making and optimization of care processes.

Influence of physically demanding occupations on the development of osteoarthritis of the hip: a systematic review

Background

Hip osteoarthritis (HOA) is a disabling disease affecting around 33 million people worldwide. People of working age and the elderly are at increased risk of developing HOA and the disease is associated with high costs at individual and societal levels due to sick leaves, job loss, total hip replacements and disability pension. This systematic review evaluated the influence of physically demanding occupations on the development of HOA in men.

Methods

Cohort studies, case–control studies and cross-sectional studies with publications in English or German, which assessed the association between exposure to physically demanding occupations and development of HOA, were searched in electronic databases (Medline, Embase, HSE-Line, Cochrane Library) and conference abstracts from 1990 until May 2020. We assessed the methodological quality of selected studies, interpreted all relative effect estimators as relative risks (RRs) and meta-analytically reviewed the effects of occupations with high physical workloads. All steps are based on a study protocol published in PROSPERO (CRD42015016894).

Results

Seven cohort studies and six case–control studies were included. An elevated risk to develop HOA was shown for six physically demanding occupational groups. Working in agriculture including fishery and forestry and food production doubles the risk of HOA. Construction, metal working and sales as well as exposure to whole body vibration while driving vehicles increases the risk by roughly 50 to 60%. Unskilled or basic level workers, who were frequently exposed to repetitive heavy manual work, had nearly a doubled risk (RR 1.89 95%CI: 1.29 to 2.77) compared to workers with lower exposure.

Conclusions

Existing studies state an association between various occupations with high physical workload and an increased risk of developing HOA. High Physical workloads include including lifting and carrying heavy loads, demanding postures, repetitive activities, long standing and running, as well as exposure to body vibrations. Occupational prevention and early detection as well as individual health promotion strategies should place their focus on reducing the impact of high physical strain at work sites.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12995-022-00358-y.

Anti-PF4 VITT antibodies are oligoclonal and variably inhibited by heparin

Background

COVID-19 vaccines have been associated with a rare thrombotic and thrombocytopenic reaction, Vaccine-induced immune thrombotic thrombocytopenia (VITT) characterized by platelet-activating anti-PF4 antibodies. This study sought to assess clonality of VITT antibodies and evaluate their characteristics in antigen-based and functional platelet studies.

Methods

Anti-PF4 antibodies were isolated from five patients with VITT secondary to ChAdOx1 nCoV-19 (n=1) or Ad26.COV2.S (n=4) vaccination. For comparative studies with heparin-induced thrombocytopenia (HIT), anti-PF4 antibodies were isolated from one patient with spontaneous HIT, another with “classical” HIT, and two patients with non-pathogenic (non-platelet activating) anti-PF4 antibodies. Isolated antibodies were subject to ELISA and functional testing, and mass spectrometric evaluation for clonality determination.

Results

All five VITT patients had oligoclonal anti-PF4 antibodies (3 monoclonal, one bi- and one tri-clonal antibodies), while HIT anti-PF4 antibodies were polyclonal. Notably, like VITT antibodies, anti-PF4 antibodies from a spontaneous HIT patient were monoclonal. The techniques employed did not detect non-pathogenic anti-PF4 antibodies. The ChAdOx1 nCoV-19-associated VITT patient made an excellent recovery with heparin treatment. In vitro studies demonstrated strong inhibition of VITT antibody-induced platelet activation with therapeutic concentrations of heparin in this and one Ad26.COV2.S-associated VITT patient. Oligoclonal VITT antibodies with persistent platelet-activating potential were detected at 6 and 10 weeks after acute presentation in two patients tested. Two of the 5 VITT patients had recurrence of thrombocytopenia and one patient had focal seizures several weeks after acute presentation.

Conclusion

Oligoclonal anti-PF4 antibodies mediate VITT. Heparin use in VITT needs to be further studied.

Evaluation of recorded video-observed therapy for anti-tuberculosis treatment

BACKGROUND: Asynchronous video directly observed therapy (VDOT) may reduce tuberculosis (TB) program costs and the burden on patients. We compared VDOT performance across three cities in the United States, each of which have TB incidence rates above the national average.METHODS: Patients aged ≥18 years who are currently receiving directly observed anti-TB treatment were invited to use VDOT for monitoring treatment. Pre- and post-treatment interviews and medical records were used to assess site differences in treatment adherence and patient characteristics and perceptions.RESULTS: Participants were enrolled in New York City, NY (n = 48), San Diego, CA (n = 52) and San Francisco, CA, USA (n = 49). Overall, the mean age was 41 years (range 18-87); 59% were male; most were Asian (45%) or Hispanic/Latino (30%); and 77% were foreign-born. The median fraction of expected doses observed (FEDO) was 88% (IQR 76-96). At follow-up, 97% thought VDOT was "very or somewhat easy to use" and 95% would recommend VDOT to other TB patients. Age, race/ethnicity, annual income, and country of birth differed by city (P < 0.05), but FEDO and VDOT perceptions did not.CONCLUSIONS: TB programs in three large US cities observed a high FEDO using VDOT while minimizing staff time and travel. Similar findings across sites support VDOT adoption by other large, urban TB programs.

A Hitherto not Described Enzyme Defect in Thrombasthenia: Glutathionreductase Deficiency

Two cases of thrombasthenia in the same family are described in which a deficiency of glutathionreductase and a reduction of reduced glutathion was found in the platelets, but no in the erythrocytes.

Digitizing Medicines for Remote Capture of Oral Medication Adherence Using Co-encapsulation

High‐resolution measurement of medication adherence is essential to personalized drug therapy. A US Food and Drug Administration (FDA)‐cleared device, using an edible ingestion sensor (IS), external wearable patch, and paired mobile device can detect and record ingestion events. Oral medications must be combined with an IS to generate precise “digitized‐medication” ingestion records. We developed a Good Manufacturing Practice protocol to repackage oral medications with the IS within certified Capsugel capsules, termed co‐encapsulation (CoE). A randomized bioequivalence study of CoE‐IS‐Rifamate (Isoniazid/Rifampin 150/300 mg) vs. native‐Rifamate was conducted in 12 patients with active Mycobacterium tuberculosis and demonstrated bioequivalence using the population method ratio test (95% confidence interval). Subsequently, CoE‐IS‐medications across all biopharmaceutical classes underwent in vitro dissolution testing utilizing USP and FDA guidelines. CoE‐IS medications tested met USP dissolution specifications and were equivalent to their native formulations. CoE combines oral medications with the IS without altering the quality of the native formulation, generating “digitized” medications for remote capture of dosing histories.

Using administrative data for primary care research: the City and East London General Practice Database Project

The City and East London General Practice Database Project was launched in 1992 to provide a framework for describing and understanding the nature of general practice in east London using routinely available administrative data from all practices in the area. It has provided an opportunity to use information on practices for research, health planning and policy, and for educational purposes. The project differs from others because it allows description in detail, clarity and depth in three distinct ways. Firstly, by covering all practices, and not just a select group, it is possible to investigate intra-health authority variability. Secondly, it has taken into account social and demographic characteristics of the practice populations, so making it possible to examine practice outputs in relation to population deprivation. Thirdly, in time, analyses using a combination of patient outcomes, morbidity information and longitudinal data become possible, making it an even more powerful information base for commissioning.

Feasibility of tuberculosis treatment monitoring by video directly observed therapy: a binational pilot study

BACKGROUND

Although directly observed therapy (DOT) is recommended worldwide for monitoring anti-tuberculosis treatment, transportation and personnel requirements limit its use.

OBJECTIVE

To evaluate the feasibility and acceptability of 'video DOT' (VDOT), which allows patients to record and transmit medication ingestion via videos watched remotely by health care providers to document adherence.

METHODS

We conducted a single-arm trial among tuberculosis (TB) patients in San Diego, California, USA, (n = 43) and Tijuana, Mexico (n = 9) to represent high- and low-resource settings. Pre-/post-treatment interviews assessed participant characteristics and experiences. Adherence was defined as the proportion of observed doses to expected doses.

RESULTS

The mean age was 37 years (range 18-86), 50% were male, and 88% were non-Caucasian. The mean duration of VDOT use was 5.5 months (range 1-11). Adherence was similar in San Diego (93%) and Tijuana (96%). Compared to time on in-person DOT, 92% preferred VDOT, 81% thought VDOT was more confidential, 89% never/rarely had problems recording videos, and 100% would recommend VDOT to others. Seven (13%) participants were returned to in-person DOT and six (12%) additional participants had their phones lost, broken or stolen.

CONCLUSIONS

VDOT was feasible and acceptable, with high adherence in both high- and low-resource settings. Efficacy and cost-effectiveness studies are needed.

A polymorphism within interleukin-21 receptor (IL21R) confers risk for systemic lupus erythematosus and is associated with malar rash in lupus patients (49.17)

Interleukin (IL) 21 is a member of the type I cytokine superfamily that exerts a variety of effects on the immune system including B cell activation, plasma cell differentiation, and immunoglobulin production. The IL21 receptor (IL21R) is expressed on B cells, T cells, NK cells, and monocyte-derived dendritic cells. The expression of IL21R is reduced in B cells from lupus patients, while IL21 serum levels are increased in both lupus patients and some lupus-murine models. We recently reported that polymorphisms within the IL21 gene are associated with increased susceptibility to lupus. Herein, we genotyped SNPs in the IL21R gene located on chromosome 16p11. We identify and confirm the association between rs3093301 and lupus in two independent European-derived and Hispanic cohorts (p=7.2X10-5). In addition, the presence of the homozygous risk genotype in rs3093301 (A/A) was associated with the development of malar rash in the European-derived female lupus patients (OR=2.83, 95% CI=1.56-5.13, p=0.00045).

C8orf13/BLK association with systemic lupus erythematosus across different ethnicities (136.28)

SLE is a complex autoimmune disease with immunological abnormalities that targets B cell functions and development. Previous genome-wide association studies identified C8orf13/BLK as a novel SLE risk factor. BLK (B lymphoid tyrosine kinase) has been shown to have potential effects on B cell develoment. The main objectives of this study are to: 1.) assess this association in independent populations and 2.) determine if BLK risk alleles correlate with alteration in peripheral blood B cell development and protein expression. We genotyped 52 SNPs within the C8orf13/BLK region in European-derived, Asian and African American populations. rs13277113 is associated with SLE in all three populations. A few novel upstream SNPs within the intergenic region demonstrate a stronger association in Asians. Flow cytometry data suggests there is a significant difference in BLK expression and T2 cells B cell numbers between high-risk and non-risk individuals based on the risk haplotype. Our results suggest that the BLK genetic polymorphisms alter immune system development and function to increase the risk for SLE development. Supported by NIH RR020143, RR015577, NIAID-DAIT-BAA-05-11, AI031584, AR053483, AR48940, AI063274, AR052125, AR043247 and OCAST # HR08-037.

[Postoperative pain after ambulatory surgery]

BACKGROUND

Outpatient surgeons were surveyed about the quality of postoperative pain therapy after outpatient interventions.

PATIENTS AND METHODS

Of 2,317 outpatient surgeons who received a questionnaire by mail, 419 responded. The return rate was 18.1%. The questionnaire collected data on the operative procedures and methods of anesthesia from 2004 and the analgesics, which were applied in the immediate postoperative period and at home. Methods and contents of quality control were registered.

RESULTS

The respondents indicated that the person responsible for the pain therapy was the surgeon in 74% of the practices, the anesthesiologist in 16%, and both in 10%. The drugs used in the practice were: novaminsulfone (34%), NSAIDs (28%), and opioids (36%). The drugs used for at-home care were: NSAIDs (58%), opioids (43%), novaminsulfone (32%), and mixed analgesics (28%). No analgesics were given by 6%, and 21% prescribed a supplementary antiemetic. Routine pain measurement was performed with pain scales in only 11% of the practices; among the certified practices, 48% performed pain measurement for quality control. Ninety-five percent of the surgeons were satisfied with the pain therapy.

CONCLUSION

This survey shows that the guidelines for acute pain therapy (http://www.awmf.de ) are only partially implemented.

Immunological memory stabilizing autoreactivity

The etiopathologies of autoimmune diseases are complex. A broad variety of cell types and gene products are involved. However, clinical and experimental evidence suggests that the importance of an individual factor changes during the course of the disease. Factors and cell types that induce acute autoreactivity and initiate an autoimmune disease could be distinct from those that drive a chronic course of that disease. Autoreactive immunological memory, in particular B cell and plasma cell memory, contributes to chronicity through several mechanisms. Formation of autoreactive memory B cells leads to an increase in the numbers of autoreactive cells. In comparison to naive B cells, these memory B cells show a decreased threshold for activation. Additionally, a fraction of memory B cells express the chemokine receptor CXCR3, which supports their accumulation within chronically inflamed tissues. This may allow their escape from mechanisms for induction of peripheral tolerance. Within the inflamed tissue, inflammatory cytokines and autoantigens provide activation signals that promote plasma cell differentiation and survival. The autoantibodies produced locally by these plasma cells contribute to the severity of inflammation. Together, an autoreactive loop of autoantibody-induced inflammation is formed. Another integral part of immunological memory are long-lived plasma cells. These cells provide persistent humoral antibody memory. Though not all autoantibodies are produced by long-lived plasma cells, these cells have a special impact on immune pathology. Long-lived plasma cells are relatively resistant to existing therapies of immunosuppression and continuously secrete antibodies, without need for restimulation. Long-lived plasma cells provide titers of autoantibodies even during clinically quiescent phases and after immunosuppression. These persisting autoantibody titers, though often low and not causing acute clinical symptoms, are likely to maintain a low level of chronic inflammation and progressive tissue destruction, which reduces the threshold for another break of immunological tolerance.

Diagnosing melanoma patients entering American Joint Committee on Cancer stage IV, C-reactive protein in serum is superior to lactate dehydrogenase

Lactate dehydrogenase (LDH) in serum has recently been introduced into the American Joint Committee on Cancer (AJCC) staging system for cutaneous melanoma because of its prognostic value. We hypothesised LDH to be of value in discriminating melanoma patients entering AJCC stage IV from patients staying in AJCC stages I, II or III. Lactate dehydrogenase was compared to the acute phase protein C-reactive protein (CRP), which we observed to reflect the course of melanoma metastasis in a previous report. In this prospective study, we measured LDH and CRP in the serum of 91 consecutive melanoma patients progressing into AJCC stage IV in comparison to 125 patients staying in AJCC stages I, II or III. Comparing distributions of the parameters by median values and quartiles by Mann-Whitney test, LDH was not significantly elevated in patients entering AJCC stage IV melanoma (P=0.785), whereas CRP was (P<0.001). Analysing the sensitivity and the specificity jointly by the areas under the receiver operating characteristics curves (ROC-AUC), LDH did not discriminate between the defined groups of patients (AUC=0.491; 95% confidence interval, 0.410, 0.581), whereas CRP did (AUC=0.933; 95% confidence interval, 0.900, 0.966; P<0.001). Upon logistic regression analysis to calculate the ROC-AUC values upon the predictive probabilities, LDH provided no additional information to CRP. Choosing a cutoff point of 3.0 mg l(-1), CRP yielded a sensitivity of 0.769 together with a specificity of 0.904 in diagnosing AJCC stage IV entry. Altogether, for first diagnosing AJCC stage IV melanoma, CRP is the superior serum marker when compared to the conventional LDH.

Expression levels for many genes in human peripheral blood cells are highly sensitive to ex vivo incubation

Monitoring of gene and protein expression in peripheral blood cells has significant potential for improving the diagnosis and therapy of many human diseases. As genomic-scale microarray and proteomic technologies are applied to peripheral blood, it is important to consider the variables that may affect interpretation of data. Here we report experiments performed to identify genes that are particularly sensitive to ex vivo handling prior to RNA extraction for gene expression microarrays or quantitative real-time RT-PCR assays. We examined Affymetrix gene expression in samples from eight normal individuals where blood was processed for RNA either immediately after blood draw or the next day following overnight incubation. These studies identified hundreds of genes that are sensitive to ex vivo handling of blood, and suggest that this is an important variable to consider when designing and interpreting human PBMC experiments.

Social inequalities in low birth weight in England and Wales: trends and implications for future population health

STUDY OBJECTIVE

To examine social inequalities and trends in low birth weight in England and Wales.

DESIGN

Analysis of routine birth data, comparing (a) couple and sole registered births, and (b) manual and non-manual occupational groups.

SETTING

England and Wales, 1993-2000.

MAIN RESULTS

Social inequalities in low birth weight were evident throughout 1993-2000: relative to the non-manual group, there is an increased risk for the manual group (range in RR 1.22-1.35) and sole registrations (RR 1.51-1.67). An estimated 6.5% (2979 births) of low birth weight in 2000 could have been avoided if risks associated with the manual group were absent, and 2.8% (1290 births) avoided if risks associated with sole registration were absent. Between 1993 and 2000, the low birthweight rate increased significantly with an estimated overall increase of 11%. Increases were evident in all social groups (15% in manual, 11% in sole registrations and 9% in non-manual); however relative to non-manual the increase in RRs were not statistically significant for manual or sole registrations. When multiple births are excluded, the rate of low birth weight is reduced but there is still a significant increase over time and social differentials are undiminished.

CONCLUSIONS

There are social inequalities in low birth weight in England and Wales that have not narrowed over an eight year period, 1993-2000. These inequalities are likely to affect childhood and adult health inequalities in the future, hence strategies will need to address differences in low birth weight and further monitoring of trends is therefore desirable.

Successful immunotherapy in early relapse of acute myeloid leukemia after nonmyeloablative allogeneic stem cell transplantation

We report on a 35-year-old woman who underwent allogeneic stem cell transplantation (SCT) in second complete remission (CR) of acute myeloid leukemia (AML) after reduced-intensity conditioning with fludarabine and 2 Gy of total body irradiation. For graft-versus-host disease (GVHD) prophylaxis, cyclosporin A (CsA) and mycophenolate mofetil (MMF) were given. On day 27 after SCT complete hematological remission and donor chimerism was documented. However, in CD34(+) bone marrow cells 28% of recipient hematopoiesis persisted. On day +59 leukemic relapse occurred. After discontinuation of CsA and onset of GVHD, complete donor chimerism and hematological CR were achieved which has been maintained for 14 months.

Did the London Initiative Zone investment programme affect general practice structure and performance in East London? A time series analysis of cervical screening coverage and asthma prescribing

A programme of incentives was set up in the London Initiative Zones to improve primary care in inner London based on the findings of the Tomlinson Enquiry in 1992. This descriptive study is a 4-y time series analysis of changes in general practice structure in East London as the result of London Initiative Zone investment, and an exploration of the possible effect of investment on practice performance. We used routinely available administrative data for the whole analysis. General practice characteristics and two selected performance indicators: the asthma prophylaxis to bronchodilator ratio and cervical cytology screening rate, for all practices in the East London and the City Health Authority for 4 y, 1993-1996, were used. Both reflect practice efficiency, but relate to different aspects of practice performance. The prescribing indicator is more indicative of the quality of clinical practise, whereas cervical screening coverage relates more to the characteristics of the practice population and to practice organisation. Repeated measures analyses were used to identify trends and to explore the relationship between changes in practice characteristics and performance. Graphical methods were used to compare East London trends with the rest of England. There were significant improvements in practice structure as the consequence of London Initiative Zone investment. There was a positive association with improvements in practice performance, but East London still lagged some way behind national patterns. The findings suggest that while improvements in asthma prescribing follow the national trend, practices have difficulty in achieving and sustaining the 80% target for cervical cytology screening, and that an overall population coverage of 80% may be in doubt.Increased investment in practice staffing may be influential in improving some aspects of performance. However, in common with other inner cities, a greater effort and more innovative strategies may be needed to achieve a standard of performance equal to the best.

Management of tuberculosis in San Diego County: a survey of physicians' knowledge, attitudes and practices

SETTING

A survey conducted in San Diego County.

OBJECTIVE

To assess local physicians' knowledge, attitudes and practices regarding tuberculosis (TB).

METHODS

The survey consisted of questions covering diagnosis and treatment of active disease, diagnosis and treatment of latent infection, and infection control. The survey was sent to physicians who reported a TB case or suspect to the local health department in the years 1995-1997.

RESULTS

Of the 384 physicians in this group, 150 (39%) returned the survey form. The percentage of physicians whose response conformed to health department guidelines varied widely from question to question (51%-94%, median 83%). Pulmonary medicine and infectious diseases specialists, physicians educated completely in the United States (US), and physicians who treated six or more TB patients in the past 2 years were more likely to give answers in agreement with health department policies.

CONCLUSIONS

Because the response rate to the survey was low, these findings may not be completely representative of the targeted group of physicians. Nevertheless, they may indicate that health care provider education about TB management standards is needed.

Passive skin penetration enhancement and its quantification in vitro

The poor penetration of drugs into the skin (and, partially, the permeation across the stratum corneum) often limits the efficacy of topical formulations. Basically, skin penetration can be enhanced by the following strategies: (i) increasing drug diffusivity in the skin; (ii) increasing drug solubility in the skin, and/or (iii) increasing the degree of saturation of the drug in the formulation. In this article, we review the literature with respect to: (i) chemical penetration enhancers, which have been shown to influence the diffusivity and/or solubility of the drug in the skin and (ii) supersaturated formulations, in which the degree of saturation of the drug is increased compared to conventional formulations. In addition, three different in vitro methods, specifically, classic diffusion cell studies, attenuated total-reflectance-Fourier transform infrared spectroscopy, and tape stripping in conjunction with an appropriate analytical technique, are considered, emphasizing their application to obtain quantitative values for skin transport parameters and to separate the kinetic or thermodynamic effects of an enhancement strategy.

Trends in the prevalence and management of atrial fibrillation in general practice in England and Wales, 1994-1998: analysis of data from the general practice research database

OBJECTIVE

To determine the prevalence of atrial fibrillation in England and Wales, and examine trends in its treatment with warfarin and aspirin between 1994 and 1998.

DESIGN

Analysis of data from the general practice research database.

SETTING

England and Wales.

PATIENTS

1.4 million patients registered with 211 general practices.

MAIN OUTCOME MEASURES

Age and sex specific prevalence rates of atrial fibrillation; percentage of patients with atrial fibrillation treated with oral anticoagulants or aspirin.

RESULTS

The prevalence of atrial fibrillation in 1998 was 12.1/1000 in men and 12.7/1000 in women. Prevalence increased from less than 1/1000 in under 35 year olds to over 100/1000 in those aged 85 years and over. There was a 22% increase in the age standardised prevalence of atrial fibrillation in men and a 14% increase in women between 1994 and 1998. The percentage of patients prescribed oral anticoagulants increased from 20% to 34% in men and from 17% to 25% in women. The percentage of men with atrial fibrillation prescribed aspirin increased from 26% to 36%, and the percentage of women increased from 24% to 36%. Applying the age and sex specific prevalence and treatment rates to the population gives an estimate of around 650 000 cases of atrial fibrillation in England and Wales. The greatest number of cases occurs in the 75-84 year old age group.

CONCLUSIONS

The number of patients in the community with identified atrial fibrillation is increasing. There has also been a pronounced increase in the percentage of patients with atrial fibrillation prescribed oral anticoagulants or aspirin.

Stabilization of supersaturated solutions of a lipophilic drug for dermal delivery

The stability of supersaturated solutions of a model lipophilic drug (LAP, a lavendustin derivative) in propylene glycol-water mixtures prepared using the method of mixed cosolvents was investigated. The solutions had a fixed degree of saturation (DS=4), but contained different ratios of propylene glycol-water. The absolute concentrations of LAP in these solutions varied by approximately a factor of 40, but the solutions at lower concentrations were no more stable than the more concentrated solutions. This shows that stability is primarily a question of the degree of saturation and not of the absolute drug concentration. Solutions of up to 5 degrees of saturation in 7:3 propylene glycol-water mixture were stable when stored for several hours; those at higher degrees of saturation recrystallized immediately. When the solutions were stirred, recrystallization occurred more rapidly. The influence of various polymeric additives on the stability of the supersaturated solutions showed that only sodium carboxymethyl cellulose had a stabilizing effect; however, the solution was very viscous and it is not clear whether the stabilizing effect was due to this high viscosity or to a specific interaction between drug and polymer.

Supersaturation: enhancement of skin penetration and permeation of a lipophilic drug

PURPOSE

To increase the dermal delivery of a lipophilic model compound (LAP), and to deduce the underlying mechanism of enhanced absorption.

METHODS

Penetration of LAP from mixtures of up to four degrees of saturation into the stratum corneum was evaluated using a tape-stripping method; epidermal permeation of the drug was measured in Franz diffusion cells. The relative diffusion and stratum corneum-vehicle partition coefficients of LAP were determined by fitting the results to the appropriate solutions to Fick's second law of diffusion.

RESULTS

Both the skin permeation rate and the amount of LAP in the stratum corneum increased linearly with increasing degree of saturation. The apparent diffusivity and its partition coefficient deduced from the penetration experiments were independent of the degree of saturation of the drug in the applied formulation, and consistent with corresponding parameters derived from the permeation experiments.

CONCLUSIONS

Supersaturation can increase the skin penetration and permeation of lipophilic drugs. The diffusion and partition parameters deduced for LAP indicate that supersaturation acts exclusively via increased thermodynamic activity without apparent effect on the barrier function of the skin per se.

Enhanced skin permeation of a lipophilic drug using supersaturated formulations

Supersaturation was used to enhance the permeation of a lipophilic model compound (a lavendustin derivative, LAP) through excised pig skin in vitro. The drug was dissolved in a series of liquid and semisolid vehicles (in which it had different solubilities) and which were prepared using either (i) the method of mixed cosolvents, (ii) the method of solvent evaporation, or (iii) the method of dissolving the drug with heating. Saturated formulations showed comparable permeation rates through the skin, independent of the absolute concentration of the drug in the vehicle. Supersaturated solutions at a degree of saturation of two resulted in a doubling of the drug permeation rate. These experiments show, therefore, that the percutaneous absorption of LAP may be consistently increased using supersaturated formulations, independent of the type and composition of the vehicles and independent of their method of preparation.

Inequalities in treated heart disease and mental illness in England and Wales, 1994-1998

BACKGROUND

Current government policy is directed towards reducing inequalities in health. General practice is increasingly the focus for health care provision in the United Kingdom and it is therefore important to understand the relationship between socioeconomic factors and health at the general practice level. A deprivation measure was used for the area in which the practice is located and two key priority areas were focused upon: mental health and heart disease.

AIM

To explore the relationship between area deprivation and the prevalence of treated heart disease and mental illness in England and Wales.

DESIGN OF STUDY

Analysis of data from medical records from practices contributing to the General Practice Research Database.

SETTING

A total of 211 practices located in England and Wales.

METHOD

The data from the practices were used to examine deprivation differentials in treated disease prevalence rates.

RESULTS

There are strong deprivation gradients (highest prevalence in the most deprived category) for treated depression, anxiety, schizophrenia, coronary heart disease and non-insulin-treated diabetes. In general the deprivation differentials are wider in the middle of the age range. Women aged 35 to 64 years in the most deprived areas had rates of treated coronary heart disease two to three times those in the least deprived areas. Men aged 25 to 44 years in the most deprived areas had rates of treated depression 50% higher than those in the least deprived areas.

CONCLUSIONS

This study has identified wide deprivation differentials in the prevalence of treated mental illness and heart disease. If all of England and Wales experienced the rates of the least deprived fifth of the population then the number of people being treated for depression, anxiety, and coronary heart disease would fall by 10%, 16%, and 11% respectively.

Linkage analysis of angiotensin-converting enzyme (ACE) insertion/deletion polymorphism and systemic lupus erythematosus

Previous studies have suggested an association between systemic lupus erythematosus (SLE) and an insertion/deletion polymorphism in the angiotensin-converting enzyme gene (ACE). This polymorphism consists of a 250-bp insertion/deletion of an alu repeat in the 16th intron of the ACE gene. Individuals homozygous for the deletion have a higher level of circulating enzyme. Due to the important role of this enzyme in regulating the renin--angiotensin and kallikrein--kininogen systems, it is possible that the ACE insertion/deletion may play a role in SLE, which can include vasculitis and vascular changes. Using primers flanking the insertion/deletion site, we have examined the ACE gene in lupus patients and family members using genomic DNA obtained from the Lupus Multiplex Registry and Repository (LMRR). We were unable to detect significant linkage or genetic association between the ACE gene and SLE.

Permeation enhancement of a highly lipophilic drug using supersaturated systems

The potential of supersaturation as a method for enhancing the membrane permeation of highly lipophilic compounds has been investigated using, as a model system, the transport of a lavendustin derivative (LAP, log K(o/w) = 5) through silicone membrane. Propylene glycol-water mixtures, which permitted the formulation of LAP at different levels of saturation, were prepared and tested for stability prior to conducting membrane permeation studies. The transport of LAP across silicone membrane from donor solutions containing the drug at different degrees of saturation (DS = 1-5) was evaluated by two independent experimental methods: (i) using attenuated total-reflectance Fourier transform infrared spectroscopy (ATR-FTIR) and (ii) using standard vertical diffusion cells followed by quantification with high-performance liquid chromatography (HPLC). Both methods demonstrated a linear relationship between the DS of the applied solution and the flux through the membrane, yielding similar values for the diffusion coefficients of LAP [diffusion cells, D = 1.75 ( +/- 0.16) x 10(-7) cm(2) s(-1) and ATR-FTIR, D = 1.42 ( +/- 0.26) x 10(-7) cm(2) s(-1)). In addition to the characterization of LAP permeation, ATR-FTIR spectroscopy enabled an examination of solvent transport across the membrane.

Treatment of leukemic relapse after allogeneic stem cell transplantation with cytotoreductive chemotherapy and/or immunotherapy or second transplants

We analyzed toxicity and efficacy of chemotherapy (CT) or second stem cell transplantation (SCT) and/or immunotherapy defined as stop of immunosuppression (IS) or donor leukocyte infusion (DLI) in 47 patients relapsing with acute leukemia. Ten patients received no treatment and 14 patients were treated with CT only. In 12 patients IS was stopped and three of them received additional CT. Five patients received DLI after CT as consolidation and one patient as frontline therapy. Five patients received a second SCT. Median overall survival after relapse was 2 months for the untreated patients, 2 months for patients receiving CT only, 2 months in patients after cessation of IS, 17 months in DLI treated patients and three months in patients receiving a second SCT. Fourteen patients achieved remission after relapse. Two with CT (2, 2 months), three with SI (3, 19, 19+ months), six with DLI (3, 8, 9, 14, 20, 36 months) and three with second SCT (2, 4, 6 months). Conventional CT was able do re-establish donor hematopoiesis and patients achieving remission showed a significantly better survival than patients with refractory disease. Patients who were brought into remission by DLI or cessation of IS had a significantly better survival than patients who achieved remission with CT alone or a second SCT. We conclude that a selected group of patients achieving remission with regeneration of donor hematopoiesis following CT might benefit from immunotherapy as consolidation.

PBPC mobilization with chemotherapy and G-CSF in patients with chronic myeloid leukemia: quantification of bcr/abl-positive cells by interphase fluorescence in situ hybridization and competitive PCR

BACKGROUND

Autografting of normal stem cells mobilized after chemotherapy is increasingly used in chronic myeloid leukemia (CML). Thus, quantification of possible contamination of progenitor cell apheresis with breakpoint cluster region (bcr)/Abelson murine leukemia (abl)-positive cells is of great clinical interest.

STUDY DESIGN AND METHODS

Two molecular methods were compared to quantify bcr/abl positivity in leukapheresis components obtained after mobilizing chemotherapy in six patients with CML. To document the efficacy of in vivo purging, the leukapheresis procedures were monitored with interphase fluorescence in situ hybridization (FISH) and quantitative competitive PCR (QC-PCR) as a ratio of bcr/abl:abl.

RESULTS

From the first to the last leukapheresis, bcr/abl positivity in FISH increased from a median of 11 percent to 33 percent. For bcr/abl transcripts, a simultaneous increase in consecutive leukapheresis procedures was seen. The median percentage of bcr cells in a bcr/abl:abl ratio was 3.1 percent in the first apheresis. In the last apheresis after the mobilization with mRNA, the QC-PCR showed a median of 19.5 percent. FISH and QC-PCR showed a statistical significant increase of bcr/abl positivity from the first to the last apheresis.

CONCLUSIONS

Both FISH and QC-PCR were reliable methods of quantifying bcr/abl positivity, and they allowed selection of the optimal apheresis component for autologous transplantation. In both methods, a significant increase in bcr/abl positivity was seen from the first to the last leukapheresis. With FISH, results can be obtained within 24 hours. This method may prevent additional contaminated leukapheresis in case of increasing percentages of bcr/abl-positive cells.

Age, sex and practice variations in the use of statins in general practice in England and Wales

BACKGROUND

Statins are highly effective in reducing the risk of sudden cardiac death and other acute coronary events in patients with pre-existing ischaemic heart disease or with raised blood cholesterol levels. However, relatively little is known about how statins are used in primary care. The objectives of this study were to investigate age, sex and inter-practice variations in the prescribing of statins.

METHODS

This was an observational study of statin prescribing rates in 288 general practices in England and Wales that contributed data to the General Practice Research Database in 1996.

RESULTS

In 1996, 0.7 per cent of men and 0.5 per cent of women received a prescription for a statin. In the subgroup of patients with a general practitioner (GP) diagnosis of ischaemic heart disease, 13.3 per cent of men and 8.2 per cent of women received a prescription for a statin in 1996. Below the age of 65 years, men with ischaemic heart disease were more likely to be prescribed a statin than were women. Patients aged 75 years and over with ischaemic heart disease were unlikely to be prescribed a statin irrespective of their sex. The percentage of patients prescribed statins in individual practices varied from 0.1 to 2.3 per cent in men and from 0 to 2.3 per cent in women. The recorded prevalence of ischaemic heart disease explained only 12 per cent of this variation in men and 7 per cent in women.

CONCLUSIONS

There are large age, sex and inter-practice variations in the use of statins in primary care, which are poorly explained by measures of health need. Developing and implementing clinical guidelines to accompany the introduction of new drugs for the management of common chronic disorders should be seen as a priority for GPs, primary care groups and the National Institute of Clinical Excellence.

Lessons from the London Initiative Zone Educational Incentives funding: associations between practice characteristics, funding, and courses undertaken

BACKGROUND

Following the Tomlinson report of 1992, London Initiative Zone Educational Incentives (LIZEI) funding was introduced for a three-year period to improve recruitment, retention, and educational opportunities for general practitioners working within inner London.

AIM

To test the hypothesis that general practices that show evidence of good organisation achieved better access to LIZEI funding than less organised practices.

METHOD

Observational practice-based study involving all 164 general practices in EAst London and the City Health Authority during the first two years of the scheme, April 1995 to March 1997.

RESULTS

Univariate analysis showed that higher levels of LIZEI funding were associated with practices where there was evidence of good organisation, including higher targets for cervical cytology screening and immunisation rates for under two-year-olds, better asthma prescribing, and training status. Using ten practice and population explanatory variables, multiple regression models were developed for fundholding and non-fundholding practices. Among non-fundholding practices, the asthma prescribing ratio was the variable with the greatest predictive value, explaining 14.7% of the variation in LIZEI funding between practices. Strong positive associations existed between taking further degrees and diplomas, practice size, training, and non-fundholding status.

CONCLUSION

Larger practices, training practices, and those that demonstrated aspects of good practice organisation gained more LIZEI funding: an example of the 'inverse funding law'. Practices within a multifund, based in the Newham locality, gained LIZEI funding regardless of practice organisation. Networks of practices, and, potentially, primary care groups, have a role in equalising the opportunities for education and development between practices in east London.

Positioning of vagal nerve stimulators: technical note

BACKGROUND

Vagal nerve stimulation has become an important treatment for patients with intractable seizure disorders. Many of these patients will require magnetic resonance imaging (MRIs) of the brain after the stimulator has been implanted to monitor underlying neurologic conditions. Functional MRI (fMRI) is also being used in the evaluation of epilepsy. With the current recommended implant techniques the magnetic field of the MRI will deactivate the pulse generator while the patient is in the supine position for the scan. A simple change in positioning of the pulse generator will help to avoid deactivating the device during an MRI. This will avoid exposing the patient to lengthy time periods with a deactivated stimulator and also allow for the performance of fMRIs and any other MRI scans needed to monitor underlying neurologic conditions.

METHODS

A working model of the NeuroCybernetic Prosthesis (NCP) pulse generator was assessed with an oscilloscope and LED light connected to it that related activation of the generator while in the MRI. This simulation was performed with the device alone, in multiple positions. Then patients with implanted devices who could personally confirm the activation of their stimulators were also studied.

RESULTS

A pulse generator placed with the electrode inputs parallel to the long axis of the body was not deactivated by the magnetic field of the MRI when the patient was in the supine position.

CONCLUSION

Changing the implant position of a vagal nerve stimulator pulse generator will help to prevent deactivation of the device while in the MRI, allowing for the performance of fMRIs while not exposing the patient to lengthy time periods with a deactivated vagal nerve stimulator.

Age- and sex-specific antibiotic prescribing patterns in general practice in England and Wales in 1996

Using data from 288 general practices in England and Wales contributing data to the General Practice Research Database in 1996, we derived age-sex specific antibiotic prescribing and exposure rates. The overall antibiotic prescribing rate was 607 per 1000 in males and 852 per 1000 in females. In both males and females, prescribing rates were highest in children aged 0-4 years and in the elderly. Prescribing rates in young and middle-aged women were substantially higher than in men of the same age. Overall, 29% of males and 39% of females were prescribed antibiotics in 1996. Children under five years of age were most likely to receive a prescription for an antibiotic. Antibiotic prescribing rates for the 288 practices in the study varied nearly five-fold, from 333 to 1616 per 1000. Reducing this variation and overall antibiotic prescribing rates will be major challenges for general practitioners.

Hematopoietic donor chimerism and graft-versus-myeloma effect in relapse of multiple myeloma after allogeneic bone marrow transplantation

A large group of patients relapsing after allogeneic bone marrow transplantation (BMT) have obtained remission after infusion of leukocytes from their original donor, suggesting a graft-versus-myeloma effect. However, side effects such as graft-versus-host disease and myelosuppression are severe, and sometimes fatal, complications of this therapeutic approach. Previously we demonstrated that patients with leukemia who lack donor hematopoiesis in relapse after BMT experience severe and lasting aplasia after infusion of donor leukocytes. In two patients - one with extramedullary and one with marrow relapse after a sex-mismatched transplantation - we analyzed hematopoietic chimerism by cell sorting and bone marrow cultures. CD34-positive cells, CD4-CD8-positive cells, committed progenitors, and LTC-IC were of donor origin, as demonstrated by two-color fluorescence in situ hybridization (FISH). Additionally, in relapse complete donor T-cell chimerism was seen. In contrast, plasma cells were of recipient origin in the patient who had a relapse in the bone marrow. Both patients were treated with infusions of donor leukocytes from their original donor. Neither patient suffered myelosuppression, and one achieved a stable complete remission.

Frequent genetic alterations in simple urothelial hyperplasias of the bladder in patients with papillary urothelial carcinoma

In order to understand the origin of bladder cancer, very early urothelial lesions must be investigated in addition to more advanced tumors. Tissue from 31 biopsies of 12 patients with urothelial hyperplasias and simultaneous or consecutive superficial papillary tumors were used to microdissect urothelium from 15- microm sections of biopsies. The biopsies were obtained with the recently developed highly sensitive diagnostic method of 5-aminolevulinic acid-induced fluorescence endoscopy (AFE). Besides flat and papillary urothelial neoplasms, the method of photodynamic diagnostics also detects simple urothelial hyperplasias as fluorescent positive lesions. In addition, 12 fluorescence-positive biopsies showing histologically normal urothelium were investigated. Fluorescence in situ hybridization was done using a dual color staining technique of biotinylated centromeric probes of chromosomes 9 and 17 and digoxigenin-labeled gene-specific P1 probes for chromosomes 9q22 (FACC), 9p21(p16/CDKI2), and 17p13(p53). Ten of 14 hyperplasias (70%) showed deletions of chromosome 9. In 7 out of 8 patients with genetic alterations in the hyperplasias the genetic change was also present in the papillary tumor. Six out of 12 samples of microdissected normal urothelium also showed genetic alterations on chromosome 9. Microdissection of urothelial lesions, obtained during AFE, has led to the first unequivocal documentation of genetic changes in urothelial lesions diagnosed as normal in histopathology. Thus, this technical approach is important to provide insight into the earliest molecular alterations in bladder carcinogenesis.