German mammography screening program: adherence, characteristics of (non-)participants and utilization of non-screening mammography-a longitudinal analysis

BACKGROUND

In Germany, all women aged 50-69 have been invited to biennial mammography screening since 2009. We aimed to assess longitudinal adherence over ten years in women aged 50 in 2009 and characterize the different adherence groups.

METHODS

Using the German Pharmacoepidemiological Research Database (GePaRD, ~ 20% of the German population), we included women aged 50 in 2009 (baseline) with continuous health insurance coverage and without breast cancer or in-situ-carcinoma. We followed them until age 59 and categorized them according to mammography screening participation into the following groups: never, 1-2, 3-4, 5-6 times. We characterized these groups, inter alia, regarding the use of other preventive measures, non-screening mammography (i.e., mammography outside the organized screening program) and menopausal hormone therapy.

RESULTS

Overall, 82,666 women were included. Of these, 27.6% never participated in the screening program, 15.1% participated 1-2 times, 31.7% participated 3-4 times and 25.6% participated regularly (5-6 times). Among regular participants, 91% utilized other preventive measures (e.g., cervical cancer screening, general health checkup) before baseline as compared to 66% among non-participants. Menopausal hormone therapy was least common among non-participants (11% vs. 18% among regular participants). Among non-participants, the proportions using ≥ 1, ≥ 2, and ≥ 3 non-screening mammographies between age 50-59 were 25%, 18%, and 15%, respectively.

CONCLUSIONS

Using a large cohort based on claims data, this study provides novel insights into longitudinal adherence to the mammography screening program and the use of mammography outside of the program in Germany. Between age 50-59, 57% of eligible women participated at least three times in the German mammography screening program and 28% (~ 3 in 10 women) never participated. Among non-participants, 15% had at least three non-screening mammographies during this period, indicating potential gray screening. Participants more often utilized other preventive measures as compared to non-participants.

Myocardial perfusion SPECT in Germany from 2012 to 2021: insights into development and quality indicators

PURPOSE

This paper summarises the results of 4 national surveys on the numbers, utilisation and technique of myocardial perfusion SPECT (MPS) from 2012 to 2021.

METHODS

A one-page questionnaire for information on MPS in 2012, 2015, 2018 and 2021 was sent to German centres practising nuclear medicine. To check for representativeness, the numbers obtained were related to official annual data and furthermore to the numbers of invasive coronary angiography procedures (ICA).

RESULTS

MPS examinations increased by > 40% from 2012 to 2021 and showed a centralisation with increasing MPS per centre. In 2020, a mild impact of the COVID-19 pandemic could be observed in the form of only a slight MPS increase, which was compensated in the following year. Outpatient care cardiologists represent the most important referrer (70%). Mostly, 2-day protocols were used. One-day protocols and stress-only protocols showed insignificant changes. The use of exercise stress decreased steadily. In 2021, exercise stress was replaced by pharmacological stress as the most frequent stress modality. Camera systems showed a shift to more SPECT-CT systems. The use of gated SPECT increased to almost 90%. Quantitative scoring showed an increasing acceptance. The ratio of invasive coronary angiographies (ICA) to MPS was between 3.9 and 4.5. A significant proportion of ICA in the context of CCS (chronic coronary syndrome) was performed without prior testing for ischaemia.

CONCLUSION

The 2012 to 2021 MPS surveys reveal a continuously growing number of examinations with only a mild temporary effect of the COVID-19 pandemic and a centralisation with increasing numbers per centre. Performance and technical data reveal a high-grade adherence of MPS practice to the current ESC guideline. A large potential of non-invasive diagnostics remains for the future.

Methodology of the brodalumab assessment of hazards: a multicentre observational safety (BRAHMS) study

INTRODUCTION

Safe and effective pharmacological treatment is of paramount importance for treating severe psoriasis. Brodalumab, a monoclonal antibody against interleukin (IL) 17 receptor A, was granted marketing authorisation in the EU in 2017. The European Medicines Agency requested a postauthorisation safety study of brodalumab to address potential safety issues raised during drug development regarding major adverse cardiovascular events, suicidal conduct, cancer and serious infections.

METHODS AND ANALYSIS

BRodalumab Assessment of Hazards: A Multinational Safety is a multicentre observational safety study of brodalumab running from 2017 to 2029 using population-based healthcare databases from Denmark, Sweden, Norway, Netherlands, Germany and three different centres in Italy. A distributed database network approach is used, such that only aggregate data are exchanged between sites.Two types of designs are used: a case-time-control design to study acute effects of transient treatment and a variation of the new user active comparator design to study the effects of transient or chronic treatment. As comparators, inhibitors of TNF-α, inhibitors of IL-12 and IL-23, and other inhibitors of cytokine IL-17A are included.In the self-controlled case-time-control design, the risk of developing the outcome of interest during periods of brodalumab use is compared within individuals to the risk in periods without use.In the active comparator cohort design, new users of brodalumab are identified and matched to new users of active comparators. Potential baseline confounders are adjusted for by using propensity score modelling. For outcomes that potentially require large cumulative exposure, an adapted active comparator design has been developed.

ETHICS AND DISSEMINATION

The study is approved by relevant authorities in Denmark, Norway, Sweden, the Netherlands, Germany and Italy in line with the relevant legislation at each site. Data confidentiality is secured by the distributed network approach. Results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

EUPAS30280.

Second dose of measles-mumps-rubella-varicella vaccine (MMRV) and the risk of febrile convulsions

INTRODUCTION

Studies have shown an increased risk of febrile convulsions (FC) after first immunization with the quadrivalent measles-mumps-rubella-varicella vaccine (MMRV) compared to a first dose of measles-mumps-rubella vaccine (MMR) only or in combination with separately administered varicella vaccine (MMR + V). Therefore, it is recommended to give MMR + V at first dose and MMRV or MMR + V at second dose. Little is known on the risk of FC after MMRV at second dose, especially whether the risk depends on age, sex, history of FC or type of first dose vaccine.

METHODS

A retrospective cohort study using claims data from the German Pharmacoepidemiological Research database (GePaRD) was performed in children born between January 1st, 2004 and October 31st, 2015 who received two doses of MMRV, MMR + V or MMR. Cases were defined as hospitalization with a diagnosis of FC without neurological conditions coded as main discharge diagnosis. Unadjusted and adjusted odds ratios (OR) with 95% confidence intevals (CIs) were calculated to compare the risk of FC. Stratified analyses were performed to examine potential effect modification by age, sex, history of FC or type of first dose vaccine.

RESULTS

In the first 30 days after second dose vaccination, 464 FCs were observed in a cohort of 528,639 children with a median age of 17 months. After adjustment for potential confounders, the adjusted OR for FC in the 30 days after vaccination was 1.25 (95% CI 0.67-2.30) for MMRV compared to MMR + V and 1.04 (0.82-1.32) for MMRV compared to MMR. History of FC was the most important risk factor with an OR of 36.26 (29.30-44.89). We found no effect modification by age, sex, history of FC, or type of first dose vaccine.

CONCLUSION

Use of MMRV at second dose is not associated with an increased risk of FC compared to MMR + V or MMR, irrespective of age, sex, history of FC, or type of first dose vaccine.

Migration of iodine-129 and iodine-127 in soils

To draw the balance of anthropogenic 129I input into European soils, the concentrations of 129I and 127I in seven soils from Lower Saxony were analyzed down to a depth of 250 cm. In comparison with pre-nuclear soils and Ukrainian soils, we detected a significant anthropogenic input of 129I. Considering the different time periods for the input of 129I and 127I it was possible to assess the dynamics of sorption processes which dominate migration and accumulation. Anthropogenic 129I was successfully used as a tracer for a clarification of the migration processes of trace elements in soils.

Characterization of pregnancies exposed to St. John's wort and their outcomes: A claims data analysis

Little is known about the utilization of St. John's wort (Hypericum perforatum L.) during pregnancy. In Germany, certain preparations of St. John's wort can be reimbursed by statutory health insurances, facilitating to investigate exposure to St. John's wort based on claims data. We therefore aimed to characterize pregnancies exposed to St. John's wort and to explore potential malformations in the babies. Using claims data from the German Pharmacoepidemiological Research Database (GePaRD), pregnancies exposed to St. John's wort during at least one trimester between 2006 and 2016 and the corresponding babies were identified. Exposure was identified via outpatient dispensations. Pregnancies were characterized regarding timing of exposure, use of other antidepressants, pregnancy outcomes and the occurrence of major malformations in the babies (not considering codes for musculoskeletal and other malformations due to low data quality in this regard). Out of 496 pregnancies with a dispensation of St. John's wort during pregnancy, 420 (85 %) had a dispensation during the first trimester. There was a dispensation of other antidepressants before pregnancy in 21 % (during pregnancy: 12 %). Eleven percent of pregnancies ended in non-live births. In 312 babies linked to 305 pregnancies, major malformations were coded in 18 babies (5.8 %), of which 17 were exposed in the first trimester. The crude relative risk of major malformations for babies exposed during the first vs. the second or third trimester only was 3.56 (0.48-26.17). Our results suggest that only in a minority of pregnancies, St. John's wort is used as an alternative to other antidepressants. Even though the relatively high rates of non-live births and major malformations after exposure to St. John's wort during the first trimester need to be interpreted with caution, the findings are striking and generate hypotheses that merit further investigation.

Follow-up of 3 Million Persons Undergoing Colonoscopy in Germany: Utilization of Repeat Colonoscopies and Polypectomies Within 10 Years

INTRODUCTION

Given the sparsity of longitudinal studies on colonoscopy use, we quantified utilization of repeat colonoscopy within 10 years and the proportion of persons with polypectomies at first repeat colonoscopy using a large German claims database.

METHODS

Based on the German Pharmacoepidemiological Research Database, we identified persons who underwent colonoscopy between 2006 and 2015 (index colonoscopy) and assessed colonoscopies and polypectomies during follow-up. We defined 3 subcohorts based on available procedure/diagnosis codes at index colonoscopy: persons with snare polypectomy, which is reimbursable for lesions ≥5 mm in size (cohort 1), with a forceps polypectomy (cohort 2), and without such procedures/diagnoses (cohort 3). We stratified all analyses by diagnostic vs screening index colonoscopy.

RESULTS

Overall, we included 3,076,657 persons (cohort 1-3: 15%, 13%, 72%). Among persons with screening index colonoscopy (30%), the proportions with a repeat colonoscopy within 10 years in cohorts 1, 2, and 3 were 78%, 66%, and 43%, respectively, and a snare polypectomy at first repeat colonoscopy was performed in 27%, 17%, and 12%, respectively. In cohort 1, 32% of persons with a (first) repeat colonoscopy after 9 years had a snare polypectomy (after 3 years: 25%). Among persons with diagnostic index colonoscopies, 80%, 78%, and 65% had a repeat colonoscopy, and 27%, 17%, and 10% had a snare polypectomy at first repeat colonoscopy, respectively.

DISCUSSION

Our study suggests substantial underuse of repeat colonoscopy among persons with previous snare polypectomy and overuse among lower risk groups. One-quarter of persons with a snare polypectomy at baseline had another snare polypectomy at first repeat colonoscopy.

How often are antidepressants prescribed off-label among older adults in Germany? A claims data analysis

AIM

To estimate the extent of off-label prescribing of antidepressants in older adults and to characterize patients with off-label vs on-label prescriptions of antidepressants using a large German health claims database.

METHODS

Using data from the German Pharmacoepidemiological Research Database (GePaRD), we conducted a cross-sectional study in adults aged 65 years or older with a dispensation of an antidepressant between 1 January 2009 and 31 December 2015 after a period of 365 days without such a dispensation. We assessed the overall and annual proportion of off-label prescriptions of antidepressants by class and individual substance.

RESULTS

Among 263 276 incident users of antidepressants, the proportion of off-label prescribing was 43.6% (95% CI 43.4-43.8%) with little variation between 2009 and 2015 (42.2-44.4%). The proportion of off-label use was higher in men (49%) than women (41%). While the proportion of off-label prescriptions was highest for tri- and tetracyclic antidepressants with 56.2% (amitriptyline 54.6%, maximum 65.9% for trimipramine), it amounted to 41.8% for selective serotonin reuptake inhibitors (citalopram 41.6%, maximum 46.0% for escitalopram) and was 51.2% for mirtazapine. Indicators of overall morbidity were similar in both groups, eg, pain was coded in 72% of off-label users vs 77% of on-label users (insomnia 20% vs 24%).

CONCLUSION

Our study suggests a high prevalence of off-label antidepressant use among older adults in Germany, which was not restricted to certain classes of antidepressants or individual antidepressants. Given the unclear risk-benefit ratio, studies investigating the safety of off-label use among older adults for individual antidepressants are urgently needed.

Anticholinergic Burden and Fractures: A Systematic Review with Methodological Appraisal

Introduction

Medications with anticholinergic activity (MACs) are used to treat diseases common in older adults. Evidence on the association between anticholinergic burden (AB) and increased risk of fractures and osteoporosis or reduced bone mineral density (BMD) is inconsistent. Our aim was to conduct a systematic review of observational studies on AB with fractures and osteoporosis or reduced BMD and provide methodological appraisal of included studies.

Methods

We searched MEDLINE, EMBASE, Science Citation Index and CENTRAL as well as grey literature from database inception up to August 2020. Eligibility criteria were: observational design, AB-exposure measured through a scale, fracture of any type or osteoporosis or reduced BMD as outcome, and reported measure of association between exposure and outcome. No restrictions related to time, language or type of data were applied. Eligibility and risk of bias assessment as well as data extraction were performed independently by two reviewers. Risk of bias of the included studies was assessed using the Newcastle–Ottawa Scale and the RTI Item Bank.

Results

The majority of the nine included studies had low risk of bias but heterogeneous methodology. No study used a new user design. Seven studies reported an increased risk of fractures associated with AB. In four studies using the Anticholinergic Risk Scale (ARS), adjusted risk of fractures was increased by 2–61% for ARS = 1, by 0–97% for ARS = 2, by 19–84% for ARS = 3, and by 56–96% for ARS ≥ 4; in three studies the ARS was aggregated, risk increased by 39% for ARS = 1–2 and 17% for ARS = 2–3. Two studies reported increased risk of fractures of 14 and 52% in the highest AB-category and one study reported that change in ARS of ≥ 3 during hospitalization was associated with a 321% increased risk in fractures. Two studies did not find an association between AB and fractures. The association between AB and osteoporosis or reduced BMD could only be assessed in two studies, one reporting increased risk of lower BMD at Ward’s triangle, the other reporting no association between AB and BMD T-score change at the femoral neck.

Discussion

Our study suggests an association between AB and increased risk of fractures with possible dose-exposure gradient in studies using the ARS. The low number of studies and heterogeneity of methods calls for the conduct of more studies.

Plain language summary

We conducted a study investigating the risk of fractures associated with anticholinergic burden, which is the result of taking one or more medication with anticholinergic activity. The results of our study suggest that persons who experience anticholinergic burden might have a higher risk of fractures. However, since we were only able to include nine studies, more studies conducted in a similar way are needed.

Electronic supplementary material

The online version of this article (10.1007/s40266-020-00806-6) contains supplementary material, which is available to authorized users.

[Use of synthetic slings and mesh implants in the treatment of female stress urinary incontinence and prolapse : Statement of the Working Group on Urological Functional Diagnostics and Female Urology of the Academy of the German Society of Urology]

Due to a safety alert issued by the US Food and Drug Administration (FDA) in 2011 for transvaginal mesh implants to treat female prolapse as a result of numerous reports of complications such as infection, chronic pain, dyspareunia, vaginal erosion, shrinkage and erosion into other organs nearly all industrial products have been withdrawn from the market in the meantime. The United Kingdom, Australia, and New Zealand extended warnings and prohibitions even on the implantation of midurethral slings (TVT, TOT). In view of these current international controversies regarding the use of implanted materials for the treatment of stress incontinence and prolapse and the lack of clear guidelines for the use of biomaterials, the opinion of the Working Group on Urological Functional Diagnostics and Female Urology should provide clarity. The Opinion is based on the SCENIHR Report of the "European Commission's Scientific Committee on Emerging and Newly Identified Health Risks", the "Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence" and in compliance with relevant EAU and national guidelines and the opinion of the Association for Urogynaecology and Plastic Pelvic Floor Reconstruction (AGUB eV). In addition, recommendations are given for the future handling of implants of slings and meshes for the treatment of stress incontinence and prolapse from a urologic viewpoint.

Anticholinergic burden and fractures: a protocol for a methodological systematic review and meta-analysis

INTRODUCTION

Medications with anticholinergic activity are used in the treatment of many diseases common in old age, including depression, psychosis, Parkinson's disease, allergies, pain and urinary incontinence. A high anticholinergic burden (ACB) is considered a major risk factor for fractures in older adults but recent studies reported inconsistent results. These inconsistencies may partly be due to differences in methodological aspects. However, no systematic review so far has addressed this association and considered study methods. Thus, we aim to conduct a systematic review and meta-analysis of observational studies addressing the association of ACB with fractures and to provide a methodological appraisal of the included studies.

METHODS AND ANALYSIS

We will search MEDLINE, EMBASE, the Science Citation Index, CENTRAL and grey literature using a strategy that combines the terms anticholinergic and fractures. We will hand search reference lists of articles. Two reviewers will independently screen all identified abstracts for eligibility and evaluate the risk of bias of the included studies using the Newcastle-Ottawa Quality Assessment Scale and RTI item bank. Discrepancies will be resolved by consensus or consultation with a third researcher. We will conduct a meta-analysis, either for the overall population or for specific and more homogeneous subgroups, if the number of studies retrieved and their heterogeneity allows it.

ETHICS AND DISSEMINATION

No ethics approval will be sought, as no original data will be collected for this review. Findings will be disseminated through peer-reviewed publication and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42018116737.

Production of χc meson pairs with additional emission

We discus mechanism of double χc production with large rapidity separation. The first order pertubative correction to gg→χcχc process includes additional emission of gluon among χc pair. We have considered real gluon distribution as well as virtual correction to the production process of χc pairs. Results for two scalar χc0χc0 and two axial mesons χc1χc1 are shown.

The benefits of co-location in primary care practices: the perspectives of general practitioners and patients in 34 countries

Background

There is no clear evidence as to whether the co-location of primary care professionals in the same facility positively influences their way of working and the quality of healthcare as perceived by patients. The aim of this study was to identify the relationships between general practitioner (GP) co-location with other GPs and/or other professionals and the GP outcomes and patients’ experiences.

Methods

We wanted to test whether GP co-location is related to a broader range of services provided, the use of clinical governance tools and inter-professional collaboration, and whether the patients of co-located GPs perceive a better quality of care in terms of accessibility, comprehensiveness and continuity of care with their GPs. The source of data was the QUALICOPC study (Quality and Costs of Primary Care in Europe), which involved surveys of GPs and their patients in 34 countries, mostly in Europe. In order to study the relationships between GP co-location and both GPs’ outcomes and patients’ experience, multilevel linear regression analysis was carried out.

Results

The GP questionnaire was filled in by 7183 GPs and the patient experience questionnaire by 61,931 patients. Being co-located with at least one other professional is the most common situation of the GPs involved in the study. Compared with single-handed GP practices, GP co-location are positively associated with the GP outcomes. Considering the patients’ perspective, comprehensiveness of care has the strongest negative relationship of GP co-location of all the dimensions of patient experiences analysed.

Conclusions

The paper highlights that GP mono- and multi-disciplinary co-location is related to positive outcomes at a GP level, such as a broader provision of technical procedures, increased collaboration among different providers and wider coordination with secondary care. However, GP co-location, particularly in a multidisciplinary setting, is related to less positive patient experiences, especially in countries with health systems characterised by a weak primary care structure.

Position paper nuclear cardiology: Update 2008

Nuclear cardiology is well established in clinical diagnostic algorithms for many years. This is an update 2008 of the first common position paper of the German Association of Nuclear Medicine and the German Association of Cardiology, Heart and Circulation Research published in 2001 aiming at an overview of state-of-the-art scintigraphic methods.

Optimizing ventilation-perfusion lung scintigraphy: Parting with planar imaging

Aim of the study was to introduce and verify a ventilation-perfusion (V/Q) acquisition protocol that incorporates new developments in scintigraphy in order to allow for a more balanced comparison with other diagnostic procedures. Methods: In 103 patients suspect of having pulmonary embolism, V/Q scans were acquired exclusively with SPECT technique. Ventilation was done with ultrafine aerosol. Planar images in eight directions were reconstructed through addition of three consecutive SPECT projections. Three referees examined the scans in regard to type, localization, and extent of V/Q defects. Results: Using this protocol, significantly more defects, especially of subsegmental size, were detected (p <0.Q1). Sensitivity, and diagnostic accuracy were also significantly improved (p <0.01) to 0.96, and 0.99, respectively. Furthermore, kappa values were increased up to 0.82 - a relevant enhancement in the ability to precisely localize V/Q defects. Conclusion: In conclusion this protocol provides high-resolution tomographic scans as well as high-quality planar images within a short acquisition time. Due to the significant increase in lesion detection, sensitivity, diagnostic accuracy, and anatomical localization of defects, it is a substantial improvement in the diagnosis of pulmonary embolism that will put V/Q scintigraphy on a par with other tomographic methods.

Myocardial perfusion scintigraphy in Germany

The working group Cardiovascular Nuclear Medicine of the German Society of Nuclear Medicine (DGN), in cooperation with the working group Nuclear Cardiology of the German Cardiac Society (DGK), decided to conduct a national survey on myocardial perfusion scintigraphy (MPS). Method: A questionnaire to evaluate MPS for the year 2005 was sent. Results: 346 completed questionnaires had been returned (213 private practices, 99 hospitals and 33 university hospitals). MPS of 112 707 patients were reported with 110 747 stress and 95 878 rest studies. The majority (>75%) was performed with 99mTc-MIBI or tetrofosmin. 201Tl stress-redistribution was used in 22 637 patients (20%). The types of stress were exercise in 78%, vasodilation with adenosine or dipyridamol in 21% and dobutamine in 1%. 99.97% of all MPS were SPECT studies. Gated SPECT was performed in 36% of the stress and in 32% of the rest studies. An attenuation correction was used in 21%. 29 institutions (8%) performed gated SPECT (stress and rest) and attenuation correction. 47% of all MPS were requested by ambulatory care cardiologists, 17% by internists, 12% by primary care physicians, 21% by hospital departments and 2% by others. Conclusion: In Germany, MPS is predominantly performed with 99mTc-perfusion agents. The common type of stress is ergometry. Gated SPECT and attenuation correction do not yet represent standards of MPS practice in Germany, which indicates some potential of optimization.

Characterization of radioiodine therapy failures in Graves’ disease

Aim of this study was a characterization of radioiodine therapy (RIT) failures in Graves’ disease without simultaneous Carbimazole. Method: 226 patients with a confirmed diagnosis of Graves’ disease received 686.8 ± 376.4 MBq of iodine-131 orally for thyroid ablation. Target dose was 250 Gy. All patients were followed up for 6 months. Therapy failures were compared with successes regarding possible influencing variables initial thyroid volume, thyroid function, immune activity (TRAb), 1-131 uptake, effective half-life, absorbed energy dose, age and gender. Results: 212 of 226 patients (93.8%) were treated successfully, 14 (6.2%) showed a hyperthyroidism relapse within 6 months which required a second radioiodine therapy. A success rate of 92.5% (62/67) could also be achieved with 67 patients who were hyperthyroid at the time of RIT. Compared to the therapy successes, the 14 failures achieved significantly lower absorbed doses (223.8 ±76.6 Gyvs. 285.2 ±82.1 Gy, ρ <0.005), but with no significant differences regarding age, thyroid volume, function or TRAb (all ρ >0.2). Of the 14 failures, η = 8 reached an absorbed dose <200 Gy and η = 1 a dose <250 Gy, although 5 of the failures reached an absorbed dose of >250 Gy. Stepwise logistic regression revealed only absorbed energy dose as a variable significantly influencing therapy success (p <0.005), but no influence of initial thyroid volume, function, TRAb value, age (all ρ >0.2) or gender (p = 0.13). Two-tailed Fisher’s exact test showed no significant influence of gender on success rates (failures/successes: male 1 /36, female 13/176, ρ = 0.48). Conclusions: Except for the absorbed energy dose, no other significant variable influencing the outcome of radioiodine therapy in Graves’ disease without simultaneous Carbimazole could be found. It should be noted, though, that 5 therapy failures (2.2%) reached an absorbed energy dose of >250 Gy.

Myocardial perfusion scintigraphy 2006 in Germany

Aim: This second survey was to deliver further information on myocardial perfusion scintigraphy (MPS) in Germany in 2006. Method: 351 questionnaires were evaluated: 207 private practices (PP), 117 hospitals (HO), 27 from university hospitals (UH). Results: MPS of 106 331 patients were reported, 85% were investigated with 99mTc-perfusion tracers. 74% [2005=72%] were performed in PP, 17% [2005=15%] in HO and 9% [2005=13%] in UH. PP, which participated in 2005 and 2006, demonstrated an increase by 3,9% (HO 0%, UH –13,0%). The type of stress was pharmacological in 27% [2005=22%]; 54% adenosine (of these 29% with exercise), 37% dipyridamole (of these 56% with exercise), and 9% dobutamine. Gated SPECT was performed in 42% [2005=36%] of all restand in 39% [2005=32%] of all stress MPS. An attenuation correction was used by 69 [2005=78] institutions. 40% of all MPS were performed in patients suspected to have CAD. 24% of all institutions reported changes in the use of MPS by competing methods. Conclusion: There is a small increase of MPS between 2005 and 2006 despite competing methods. Gated SPECT has experienced more acceptance. Suspicion of CAD is an important indication of MPS. In order to tap the full potential of MPS a gated SPECT should be performed routinely.

Morphological, chemical, and antigenic organization of mammalian C-type viruses

New features in the architecture of mammalian type C viruses, in particular knoblike surface projections and hexagonally arranged subunits on the core shell could be demonstrated by electron microscopy, taking advantage of newly developed preparation techniques. As examples, murine leukemia viruses (MuLVs) and newly isolated porcine and bovine C viruses are presented. The major proteins of a MuLV were isolated and partially characterized in chemical terms and with respect to their serological and other biological activities, such as interfering and hemagglutinating (HA) capacity. Most of the characterized proteins could be localized in particular substructures of the virion either by selective removal or isolation of electron microscopically identifiable constituents. The information obtained allowed the design of a more detailed model of mammalian C viruses. Special attention was devoted to the further characterization of interspecies antigens of mammalian C viruses. Different antigenic determinants were revealed. Their distribution allows further subgrouping of mammalian C viruses.

Direkte allosterische Wechselwirkung von Sauerstoff und Bicarbonat: N-Acetyl-Ala-Ser-Phe, die N-terminale Sequenz der β-Ketten der Hämoglobine des Nilkrokodils (Crocodylus niloticus) und des Mississippi­ krokodils (Alligator mississippiensis) / Direct Allosteric Interaction of Oxygen and Bicarbonate: N-Acetyl-alanyl-seryl-phenylalanine, N-Terminal Sequence of the β-Chains of the Haemoglobins of Nil Crocodile (Crocodylus niloticus) and Mississippi Crocodile (Alligator mississippiensis)

To elucidate the molecular mechanism of the direct allosteric exchange of oxygen and hydrogen carbonate in the hemoglobins of crocodiles, the N-terminal sequence of the β-chains of the crocodiles of the Nile (Crocodylus niloticus) and of the Mississippi (Alligator mississippiensis) was studied. The N-terminal end of the peptide is blocked. By mass spectrometry the N-terminal sequences of both species were found to be N-acetyl-alanyl-seryl-phenyl-alanine. These data explain the absence of hemoglobin-phojphate interaction, the data are in good agreement with the stereochemistry postulated for allosteric exchange of oxygen and hydrogen carbonate in crocodilian hemo­ globins.

Notizen: Spontane Leukämie der AKR-Mäuse. Erfolgreiche passive Immunisierung mit Ziegen- Antikörper gegen isoliertes Glykoprotein gp71 des Friend-Leukämie-Virus /Spontaneous Leukemia of AKR Mice. Successful Passive Im m unization with Goat Anti­ bodies against Isolated Glycoprotein gp71 of Friend Leukemia Virus

The occurrence of fatal spontaneous leukemia in AKR mice could be drastically reduced by passive immunization with goat antibody against isolated murine Friend virus glycoprotein gp71, possessing high group specific reactivity. The success depended on the time of antibody application. The best results were achieved when mothers and babies were inoculated.

[Psammomatous melanotic schwannoma as indicator of a Carney complex]

Within a few months a 31-year-old female patient was diagnosed with a psammomatous melanotic schwannoma, an atrial myxoma and microfollicular adenomas in both thyroid lobes. Therefore, sufficient diagnostic criteria of a Carney complex were fulfilled. The Carney complex is an inherited autosomal dominant disorder with highly variable phenotypes, which was initially described by Carney in 1985 as a complex of myxomas, spotty skin pigmentation and endocrine overactivity. Pathologists should consider this differential diagnosis in reports when confronted with a psammomatous melanotic schwannoma.

Use of myocardial perfusion imaging and estimation of associated radiation doses in Germany from 2005 to 2012

PURPOSE

For several years the Working Group Cardiovascular Nuclear Medicine of the German Society of Nuclear Medicine has been performing a regular survey to obtain information on technique, utilization and development of myocardial perfusion scintigraphy (MPS). Currently, data of six surveys from 2005 to 2012 are available. The aim of this paper is to deliver a general and comprehensive overview of all surveys documenting the course of patient doses over time and the development of the method.

METHODS

A one-page questionnaire with number of MPS patients, number of stress and rest MPS, referral structure and several technical issues was sent to all centres performing MPS in Germany and evaluated. With the data on protocol utilization, effective MPS patient doses were estimated.

RESULTS

MPS per million population (pmp) varied between 2,380 and 2,770. In 2012, MPS pmp showed a slight increase for the first time. From 2005 to 2009 the angiography to MPS ratio increased from 3.4 to 4.4, and the revascularization to MPS ratio decreased from 0.66 to 0.53. In 2012, both indices demonstrated an opposite trend for the first time (4.1 and 0.55). A total of 108 centres participated in all surveys. They showed an increase in MPS patients of 4.0 % over the reporting period. In 2012, more than 50 % of the centres experienced no change or an increase in MPS numbers. The leading single competitor was MRI, followed by angiography and stress echocardiography. (201)Tl studies have decreased since 2005 from 20 to 5 %. (99m)Tc MPS studies showed a mild increase in 2-day protocols. In 2012, the average effective dose per patient was estimated at 7.4 mSv. Due to the decreasing use of (201)Tl, a mild decline over the observation period can be documented. Dynamic exercise stress was the most common stress test and adenosine the leading pharmacological stress agent, with a growing percentage. In 2012, the regadenoson percentage was 9 %. Gated single photon emission computed tomography (SPECT) noted an increasing acceptance with >70 % in 2012. The segmental scoring of perfusion studies had a low acceptance. Ambulatory care cardiologists represented the major referral group.

CONCLUSION

Germany has a moderate to moderate-high MPS utilization rate. Nevertheless, coronary artery disease (CAD) diagnosis and disease management are dominated by angiography. The survey data reveal a positive trend in MPS and a decrease in average patient dose reflecting good practice with guideline adherence, the implementation of technical improvements and success in training.

[Myocardial perfusion scintigraphy 2008 in Germany - results of the fourth query]

AIM

The working group Cardiovascular Nuclear Medicine of the German Society of Nuclear Medicine in cooperation with the working group Nuclear Cardiology of the German Cardiac Society herewith present the results of the 4th survey on myocardial perfusion scintigraphy (MPS) of the year 2008.

METHOD

310 questionnaires (191 private practices (PP), 93 hospitals (HO), 31 university hospitals (UH)) were evaluated.

RESULTS

MPS of 98947 patients were reported. 15% of them were younger than 50 y, 57% between 50 and 70 y and 28% older than 70 y. 88% [2007: 83%] of all were studied with Tc-99m perfusion tracers. The patient radiation exposure of a stress and rest protocol considering German standard recommended doses was 8.5 mSv, of a stress-only protocol 1.9 mSv. 77% [2007: 76%] of the MPS were performed in PP, 15% [2007: 15%] in HO and 8% [2007: 9%] in UH. From 2005 to 2008 there was a mild increase in the MPS numbers by 1.2% (PP +7.1%, HO -5.5%, UH -31.4%). The type of stress was pharmacological in 30% [2007: 27%]; 68% adenosine (of these 22% with exercise), 29% dipyridamole (of these 64% with exercise), and <1% dobutamine. Gated SPECT was performed in 46% [2007: 47%] of all rest and in 42% [2007: 44%] of all stress MPS. 62% [2007: 61%] of all institutions did not use perfusion scores.

CONCLUSION

The MPS numbers from 2005 to 2008 in Germany can be regarded as stable. However, there are considerable shifts from HO and UH to PP. The well known potential of MPS considering risk stratification and functional analysis has not been tapped so far. Both gated SPECT and a quantitative perfusion analysis should be performed routinely in every patient.

[Myocardial perfusion scintigraphy 2007 in Germany--results of the query and current status]

AIM

This third survey of the working group Cardiovascular Nuclear Medicine of the German Society of Nuclear Medicine in cooperation with the working group Nuclear Cardiology of the German Cardiac Society was to deliver information on the procedures and in particular on the development of myocardial perfusion scintigraphy (MPS) from 2005 to 2007.

METHOD

370 questionnaires (222 private practices (PP), 117 hospitals (HO), 31 university hospitals (UH)) were evaluated.

RESULTS

MPS of 114,374 patients were reported, 83% were investigated with 99mTc-perfusion tracers. 76% [2006=74%] were performed in PP, 15% [2006=17%] in HO and 9% [2006=9%] in UH. Diabetics represented 21% of all MPS patients in 2007. Data of 215 institutions which participated all from 2005 to 2007 showed an increase in MPS of 2.3% (PP +6.8%, HO -4.5%, UH -18.2%). The type of stress was pharmacological in 27% [2006 = 27%]; 67% adenosine (of these 25% with exercise), 31% dipyridamole (of these 55% with exercise), and 2% dobutamine. Gated SPECT was performed in 47% [2006 = 42%] of all rest and in 44% [2006 = 39%] of all stress MPS. 61% [2006 = 83%] of all institutions did not apply perfusion scores. 20% [2006 = 24%] of the institutions reported changes in the use of MPS by competing methods.

CONCLUSION

There is a small increase of MPS between 2005 and 2007 despite competing methods. Gated SPECT has experienced more acceptance, but is still underrepresented. As compared to the European average and general standards of MPS a considerable backlog accounts to pharmacological stress tests, gated SPECT and perfusion scores.